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. He is self-referred with detoxification and withdrawal management followed by admission for inpatient rehabilitation and substance use disorder treatment. The patient has a history of long-standing substance use disorders with alcohol and stimulant (cocaine) class substances with a chronic relapsing course and up to ten relapses following prior treatments. The patient has no history of withdrawal seizures or delirium tremens. He was self-referred due to difficulty with the social environment and coping problems mostly related to the substance use disorders. His history of substance use included use of large quantities of alcohol and cocaine on a daily continuous basis. He identified health concerns and psychosocial stressors and consequences as a major concern including problems with housing, occupational, primary support, and social environment domains. The patient has a history of psychiatric disorder with a diagnosis of an unspecified anxiety disorder; he denied history of psychiatric hospitalization or suicidal behavior. He had chronic general medical problems that included hypertension, peripheral neuropathy, and obesity, and he had neglected his general health while using substances of abuse including noncompliance with treatment for the hypertension. There were no significant withdrawal symptoms or post-acute withdrawal symptoms though he displayed anxiety and motor agitation. He also reported insomnia. Throughout the inpatient stay, the patient remained stable with mental status and had engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour nursing monitoring. The patient was discharged 3 weeks later with plans for clinically appropriate aftercare with referral for extended residential level treatment. 

The inpatient substance-related rehabilitation treatment with transfer to residential level care was denied based on New York State Office of Alcoholism and Substance Abuse Services Level of Care for Alcohol and Drug Treatment Referral (OASAS LOCADTR) 3.0 Criteria. 

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

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and nicotine/tobacco use disorders. He had self-referred and received inpatient level rehabilitation treatment. 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 inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure, or 24-hour nursing monitoring, as the health plan asserts. The application of New York State Office of Alcoholism and Substance Abuse Services Level of Care for Alcohol and Drug Treatment Referral (OASAS 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, also as the health plan asserts. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the requested dates of service is not met in this case scenario, consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below, and with the application of New York State Office of Alcoholism and Substance Abuse Services Level of Care for Alcohol and Drug Treatment Referral (OASAS LOCADTR) 3.0 Criteria.