Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse Inpatient

The patient is a male who presented  for inpatient rehabilitation substance use disorder treatment to address substance use disorder with stimulants (crack cocaine) and alcohol. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder that had begun in adolescence with multiple prior treatments with relapses though he had achieved a long period of sobriety in the past with up to four years of abstinence. His relapse was precipitated by the death of a friend. He was using cocaine in large quantity with up to $100 worth in a day and daily use of alcohol with up to two pints of liquor.

The patient was admitted to inpatient rehabilitation treatment following detoxification with vitamins and nicotine replacement to address tobacco dependence. He was provided comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with groups and individual therapy, as well as 12-step recovery groups and other therapeutic activities. He was prescribed Campral to address craving and the alcohol use disorder.
Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was enthusiastically participating actively in treatment with continued risk for relapse; the patient had no severe withdrawal symptoms or post-acute withdrawal symptoms; he was participating actively in treatment, and had no complications with respect to biomedical, general medical, emotional or other treatment domains. Mental status examinations/progress notes reflected stable mood with sleep, appetite and energy that were okay. He was social with peers. He was discharged with referral to outpatient aftercare as clinically appropriate.

The health plan's determination is upheld.

The requested health service/treatment of inpatient rehabilitation was not medically necessary for this patient. The proposed inpatient level treatment noted in the clinical summary could have been safely and effectively provided at a lower level of care.
The clinical features and indicated treatment dimensions of this patient's alcohol and cocaine use disorders did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine and a history or schizoaffective disorder. Moreover, the patient had been evaluated and cleared with regard to safety concerns and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment. Any indicated treatment for the cocaine and the alcohol use disorders in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization that occurred during his detoxification treatment immediately prior to entering rehabilitation treatment.
Thus, the requested inpatient rehabilitation was not medically necessary in this case. This answer is consistent with established practice guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) Criteria, as referenced below, including the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below.