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 who was referred 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. The history of substance use included use of up to one-half pints of liquor and four 40-ounce beers per day and $ (dollar) 100 worth of crack cocaine per day. The patient was self-referred and indicated that he was tired of feeling unwell. He had an extensive history of detoxification treatments and rehabilitation treatment with relapses; the more recent substance-related treatment was 6 months ago. The patient has a history of psychiatric disorder and treatment for bipolar disorder and post-traumatic stress disorder (PTSD) treated with Lexapro and Seroquel and he presented without severe symptoms of depression. The patient has no history of psychiatric hospitalization. The patient is married and unemployed with public assistance and domiciled in a shelter or group home. He has 12 children. There were no reported legal issues, but there is trauma history. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. He did not report suicidal ideation or aggressive impulses. Upon admission to inpatient level services, the patient received comprehensive evaluation and treatment and involvement with groups, as well as peer supported recovery meetings, and other therapeutic activities within the treatment milieu. Psychiatric evaluation was provided, and he was prescribed Lexapro and Seroquel with as needed (PRN) use of trazodone for insomnia/sleep, and other comfort drugs. The patient continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring and was discharged against medical advice after ten days with referral for clinically appropriate care of the mental health and substance use disorders. The denial of coverage is based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and medical necessity indicating that there were no general medical or psychiatric issues warranting 24-hour nursing care and that treatment could have been provided in a less restrictive treatment setting. 

The proposed treatment was not medically necessary. 

The health plan's determination is appropriate in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3 Criteria and prevailing standards of medical practice. 

In this case, the patient could have been reasonably managed with lower-level care in a less restrictive treatment setting, as the health plan asserted. During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his 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 monitoring for the time interval under review.