Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder
Treatment: Inpatient substance use rehabilitation treatment
The insurer denied the Inpatient substance use rehabilitation treatment.
The denial is upheld.

The patient is an adult male. He received inpatient psychiatric treatment and was
transferred for inpatient level substance use disorder rehabilitation treatment to
address use of stimulants (crack cocaine) and alcohol class substances. The
patient was tobacco dependent. He had no past history of delirium tremens or
withdrawal seizures. He reported onset of alcohol use at an early age, with
subsequent use of crack cocaine with progression of the substance use disorders,
escalating to frequent or daily continuous use of crack cocaine up to $20 per day, or
six bags, and alcohol use, with up to one pint of liquor plus beers.

The patient had previously engaged in substance use disorder treatment with
relapses. He reported no sustained sobriety in the past despite up to eight prior
detoxification and rehabilitation treatment episodes.

The patient has a history of psychiatric disorder and treatment for recurrent major
depressive disorder. The patient has a history of psychiatric hospitalization, as well
as history of suicidal and/or self-harming behaviors. He was currently in treatment
for the depressive disorder and was prescribed psychotropic medication.

The patient completed his inpatient level rehabilitation treatment with
discharge and referral for mental health aftercare with an appointment in four weeks
and immediate step down for substance use disorder treatment in the community
with recommendation for involvement with recovery groups; he declined medication
assisted treatment for the alcohol and nicotine use disorders. Overall, the patient
was compliant with the treatment, adherent with medications and participated
actively in treatment during his inpatient stay.

No, the Inpatient substance use rehabilitation treatment was not medically
necessary.

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. 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 or safety issues in this case that would have required
inpatient level services and rehabilitation treatment. Moreover, the patient had
previously received substance use disorder treatment with knowledge of treatment
and access to lower level care with sober housing or support, and the availability of
peer support, and he was motivated to participate in rehabilitation treatment, as
noted. Thus, the Inpatient substance use rehabilitation treatment was not medically
necessary.

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 peer-supported 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. He received psychiatric
consultation on a prn (as needed) basis, and was prescribed sertraline, aripiprazole
and valproate with the prn (as needed) use of trazodone; these medications were
prescribed at therapeutic dosages and were well-tolerated. The patient participated
in activity therapies and other therapeutic interventions to improve insight and life
skills while working on a relapse prevention plan and development of better coping
skills. He received vitamin replacement therapy, but declined nicotine replacement.

This answer is consistent with prevailing standards of medical 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
Determination) 3.0 Criteria, referenced below.