Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male who received detoxification treatment earlier this year and was transferred for inpatient rehabilitation substance use disorder treatment in order to address use of alcohol and stimulant (cocaine) class substances. The patient has no reported history of withdrawal seizures or delirium tremens though there was a history of severe withdrawal symptoms in the past during detoxification treatment. The substance use included use of up to one pint of alcohol per day, $100 worth of crack cocaine daily and one to three grams of cocaine with inhalation. The patient was also tobacco dependent and had a history of opioid use disorder.

The patient has a history of psychiatric disorder and treatment for bipolar disorder and presented with severe symptoms of depression and anxiety. The patient has a history of psychiatric hospitalizations, and multiple detoxification and substance use disorder treatment episodes with no sustained sobriety or abstinence. The patient was noted to be engaged in the therapeutic activities, social with peers and participating in recovery groups, and adherent with medications. From date of admission to discharge, the patient continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring and was discharged with clinically appropriate care of his substance use disorders with referral for outpatient level care, and psychiatric follow up for the co-occurring mood disorder. The patient had no significant withdrawal or post-acute withdrawal symptoms other than cravings, no safety concerns, and no biomedical complications. 

The denial was on the basis of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that there were no mental health or biomedical issues requiring 24-hour nursing care or inpatient structure and monitoring. The denial determination indicated that residential level care was appropriate in this case. 

The appeal was on the basis of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria referencing the treatment history and presence of comorbidity requiring active psychiatric management. The issue under review is inpatient rehabilitation substance use disorder services.

The proposed treatment was not medically necessary for this patient. 

In this case, the patient could have been reasonably managed with lower-level care in a less restrictive treatment setting. During the time interval under review, based on the documentation submitted for review, the patient was noted to be in no distress 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 or safety concerns that would have warranted inpatient level of care, structure or 24-hour nursing monitoring for the time interval under review. 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 Level of Care Utilization System (LOCUS) and the American Society of Addiction Medicine (ASAM) Criteria referenced below, did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the admission and continued rehabilitation substance use disorder services was not met in this case scenario, also consistent with the scientific literature referenced below, as well as prevailing standards of medical practice.