Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female, self-referred following a recent detoxification treatment episode for inpatient rehabilitation (rehab) substance use disorder treatment in order to address use of alcohol, cannabis, and stimulant (cocaine) class substances. Her history of substance use included use of up to two pints of vodka per day, $50 worth of crack cocaine up to three times per week or less, and intermittent use of marijuana. The patient was self-referred and indicated that she needed rehab. The patient has a history of psychiatric disorder and treatment for schizoaffective disorder bipolar type treated with Abilify and Paxil. The patient has a history of psychiatric hospitalizations, and multiple detoxification and substance use disorder treatment episodes including the recent detoxification treatment.

Drug screen was positive and consistent with history. The patient is tobacco dependent. Upon admission to inpatient level services, the patient received comprehensive evaluation and treatment. Psychiatric evaluation was provided, and the patient was prescribed the Abilify and Paxil with as needed (PRN) use of Vistaril for insomnia/sleep. The patient engaged in substance use disorder rehabilitation treatment. The patient had requested medication assisted treatment with Vivitrol and was started on naltrexone with a subsequent injection of Vivitrol 380 milligrams with plans for continued treatment. The patient continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour monitoring and was discharged 17 days later with disposition to outpatient level care, and psychiatric follow up for the co-occurring disorder. 
During the time interval under review, the patient remained stable and had no significant withdrawal or post-acute withdrawal symptoms, no safety concerns, and no biomedical complications. 

The denial was on the basis of medical necessity and New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient could have been treated with lower-level care suggesting residential treatment as being appropriate. The appeal was on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient was at high risk for relapse together with general medical and psychiatric comorbidity that warranted inpatient level care.

The proposed treatment was not medically necessary.

The patient presented with substance use disorders, diagnosed with alcohol, cannabis, and stimulant/cocaine use disorders. She received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues. 

She continued treatment for the co-occurring psychiatric disorder, as well as started medication assisted treatment. During the time interval under review, the patient was noted to be in no distress with reasonable functioning and active participation in treatment. 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, as well as the Level of Care Utilization System (LOCUS) and the American Society of Addiction Medicine (ASAM) Criteria 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 admission and continued rehabilitation substance use disorder services is not met in this case scenario.