Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Use Disorder.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a male. He received detoxification treatment and presented for inpatient level substance use disorder rehabilitation treatment to address use of stimulants (crack cocaine) and alcohol class substances. The patient was tobacco-dependent at one pack per day; he had no past history of delirium tremens or withdrawal seizures. He reported onset of alcohol and marijuana use at an early age escalating to daily continuous use of crack cocaine up to $300 per day and alcohol with up to two pints of liquor plus six 12-ounce beers. 

The patient had previously engaged in substance use disorder treatment with relapses. He reported only a couple years of sobriety in the past. 

The patient had no general medical issues. There was a history of psychiatric disorder and treatment for depression, and the patient has a history of psychiatric hospitalization, but denied suicidal or self-harming behaviors. He was not currently in treatment for the depressive disorder and was not taking psychotropic medication.

The patient was motivated for rehabilitation treatment. The patient exhibited fair, but limited insight and fair judgment and control of impulses except when using substances. 

There were no severe symptoms on mental status examination; the patient had no symptoms of mania, psychosis, perception, cognition, or thought disorder. The patient was described as cooperative with good eye contact. He was not depressed, but exhibited mild symptoms of anxiety and complained of insomnia. He did not present with significant post-acute withdrawal symptoms. 

The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the inpatient treatment program. The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment. The patient participated in activity therapies and other therapeutic interventions to improve insight and life skills. He received vitamins and nicotine replacement therapy. The patient completed his rehabilitation treatment with discharge. He declined referral for aftercare and declined medication-assisted treatment.

No, the Inpatient admission was not medically necessary for this patient.

The substance abuse rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or monitoring of an inpatient setting or 24-hour monitoring in order to safely and effectively participate in rehabilitation substance use disorder rehabilitation treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required continued inpatient level services and rehabilitation treatment. Moreover, the patient had support for the substance use disorder treatment with access to sober housing and peer support, and he was motivated to participate in rehabilitation treatment, as noted. Thus, the requested benefit of Inpatient admission was not medically necessary.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, as well as New York State instruction regarding medical necessity reviews and the application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria, referenced below.

The patient had received detoxification treatment and was motivated to transition and actively engage in rehabilitation treatment without biomedical complications or significant withdrawal or post-acute withdrawal symptoms. He had prior exposure to substance use disorder treatment, and was able to engage and participate actively in the treatment plan without complication. There were no severe psychiatric disturbances or general medical concerns that would have required inpatient level services, structure or monitoring. The patient was noted to benefit in all aspects of his treatment plan throughout his stay despite his decision to decline referral for aftercare and/or medication assisted treatment. He had access to sober housing from which substance use disorder treatment could be received. Thus, the patient's substance use disorder rehabilitation treatment could have been effectively provided at a lower level of care including sober housing or supports, and other supportive services in the community including peer support through 12-step recovery groups such as Alcoholics Anonymous (AA). Moreover, the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines does not support treatment at the inpatient level of care, as the health plan asserts.