Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Acute Inpatient Rehabilitation Services
The insurer denied the Acute Inpatient Rehabilitation Services
The denial is upheld. 

The patient is an adult male who presented for inpatient rehabilitation treatment to address substance use disorder with cannabis (marijuana) and sedative-hypnotic-anxiolytic (Xanax) use disorders. The patient was tobacco dependent at one-half pack per day. Substance use began in adolescence and progressed as a young adult to daily continuous use of heroin and cocaine, as well as the current use of Xanax up to 6 milligrams daily and one joint of marijuana daily; his opioid and cocaine use disorders were in full remission and he was not on medication assisted treatment. The patient had no past history of withdrawal seizures or delirium tremens or other episodes severe withdrawal symptoms. Past attempts at substance use disorder treatment had failed to result in sustained abstinence or engagement in a recovery process. The patient's substance use was associated with ongoing stressors that included the primary support and occupational domains. The admission and self-referral for inpatient level substance use disorder rehabilitation treatment was supported by his family with whom he lived.

The patient was admitted to inpatient rehabilitation treatment with 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 other therapeutic activities. He was prescribed Depakote 500 milligrams twice daily and trazodone 100 milligrams at bedtime with vitamin supplements and the availability of comfort medications and nicotine replacement therapy. The patient was provided the opportunity to participate in treatment with intensive services, monitoring, and structure provided within the inpatient treatment setting. He had no severe withdrawal symptoms. He had no complications with respect to biomedical, general medical, emotional or other treatment domains. The treatment team was working with the patient to enhance motivation including discussion of a discharge plan and aftercare arrangements with the goal of building sober supports including work with a sponsor and continued recovery group participation. The patient declined medication assisted treatment. He was discharged from inpatient treatment after successfully completion of the program with immediate transfer to outpatient recovery services. He was provided with recommendations for aftercare and indicated his desire to follow up with treatment with continued family support.

No, the proposed Acute Inpatient Rehabilitation Services are not medically necessary for this patient.
The patient did not require the structure or monitoring of an inpatient setting in order to address the issues related to his substance use disorders, or to receive safe and effective substance use disorder treatment. There were no biomedical or psychiatric issues that would have required inpatient level structure, monitoring or services, as noted below.  Additionally, the requested inpatient admission is not consistent with prevailing standards of professional practice or consistent with published practice guidelines (best practice) and the American Society of Addiction Medicine (ASAM) criteria referenced below. New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines do not support the medical necessity for treatment at an inpatient level of care.

The inpatient substance use rehabilitation treatment that was provided for this patient could have been reasonably provided at a lower level of care. The patient had previously been in treatment for the substance use disorders with exposure to recovery and rehabilitative techniques, and he was generally motivated to participate in treatment in view of family pressure and the psychosocial issues that prompted his presentation for treatment. The patient would have been expected to effectively engage in rehabilitation services with an alternative level of care with sober living or supports and monitoring for abstinence. 

Thus, the patient did not need the structure of an inpatient setting or 24-hour monitoring in order to be effectively treated. Again, the requested benefit of inpatient admission for substance use disorder rehabilitation treatment is not consistent with prevailing standards of professional practice, or consistent with published practice guidelines (best practice) including the LOCUS [level of care utilization system for psychiatric and addiction services] Guidelines (Reference 13) or the American Society of Addiction Medicine (ASAM) criteria referenced below, and is not in keeping with 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, also referenced below.