Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Rehabilitation Admission
The insurer denied: Inpatient Rehabilitation Admission
The denial is upheld.

The patient is an adult male who self-referred for inpatient rehabilitation and substance use disorder treatment. The patient has a history of longstanding substance use disorders with alcohol and more recent use of stimulant (cocaine and other amphetamine) class substances with prior treatments as an outpatient which failed to result in sustained abstinence or a successful recovery process. The patient has no history of 
withdrawal seizures or delirium tremens but reported frequent blackouts. He self-referred due to a baby coming and due to difficulty with the social environment and coping problems mostly related to the substance use disorders in the context of family problems and feeling unwell. His history of substance use included use of large quantities of alcohol with up to 30 drinks/beers in a day and up to 80 "balls" of cocaine on a daily continuous basis, as well as small amounts of methamphetamine. He identified psychosocial stressors and consequences as a major concern including problems with primary support and social environment domains. The patient has a history of psychiatric disorder with a diagnosis of an unspecified anxiety and depressive disorder, as well as trauma history and reports of flashbacks and nightmares; he denied history of psychiatric hospitalization or suicidal behavior. The patient had been medically screened with detoxification prior to admission. Evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight, intact judgment, and poor control of 
impulses. There were no significant withdrawal symptoms or post-acute withdrawal symptoms though he displayed anxiety and motor agitation. He also reported insomnia and disturbed sleep-as noted. The patient engaged in substance use disorder rehabilitation treatment. He was noted to be engaged in the therapeutic activities, social with peers, and participating in recovery groups. Throughout his brief inpatient stay, the patient remained stable with mental status and had engaged with the treatment regimen, as noted. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour nursing monitoring. The patient was discharged on day number (#) 5 against medical advice with plans for clinically appropriate aftercare of his substance use disorders with referral back to outpatient level treatment and recommendation for involvement in 12-step recovery groups with 
obtainment of a sponsor. 

The requested inpatient substance-related rehabilitation treatment was not medically necessary.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and other amphetamine use disorders. He received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. During the time interval under review, the patient was noted to be in no apparent distress other than anxiety with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his brief inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of New York State Office 
of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria (referenced below) did indicate that the patient was 
clinically appropriate for treatment with lower-level care in a less restrictive treatment setting. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the dates of 
service under review is not met in this case scenario, consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below, and with the required application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.