Appeal type: Medical necessity
Decision: Upheld

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

The case involves an adult male medically screened and admitted for inpatient rehabilitation substance use disorder treatment in order to address use of stimulant (cocaine) and cannabis (marijuana) class substances with a history of opioid use disorder in full remission with medication assisted treatment (Suboxone). The patient has no reported history of withdrawal seizures or delirium tremens, or severe withdrawal symptoms. His history of substance use included use of up to one gram of crack cocaine every other day and daily use of marijuana. The patient has a history one or more prior treatment episodes with relapse. The patient has a history of psychiatric disorders but no suicidal behavior or psychiatric hospitalizations. He had diagnoses of attention deficit hyperactivity disorder (ADHD), 
depression and anxiety with associated treatments including medication assisted treatment with Suboxone. The patient had no acute general medical issues; he was medically screened upon admission including laboratory testing that was normal or unremarkable and drug screening that was positive for cocaine and tetrahydrocannabinol (THC). There were prominent legal issues, and the patient was on parole with charges pending for possession and criminal trespass. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, and fair to good insight and judgment. 
Denial was based on the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines indicating that the criteria for inpatient level treatment was not met. 
The treatment facility asserted that medical necessity was met on the basis of the longstanding use of multiple substances and the patient's need for monitoring and the structure of an inpatient rehabilitation setting.

The proposed treatment and the requested benefit of inpatient substance abuse rehabilitation treatment was not medically necessary.

This patient presented with substance use disorders, diagnosed with cannabis and stimulant/cocaine use disorders. The patient was medically screened and had no acute general medical issues or general medical issues that warranted inpatient level care-as the health plan indicated in the denial. The patient readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or acute psychiatric treatment issues or instability of the co-occurring psychiatric disorders, i.e., he was stable with current treatment. During the time interval under review, the patient was noted to be in no apparent distress and was eating and sleeping okay, and he displayed reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout the 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 monitoring. The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria (referenced below) 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 inpatient rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines.