Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He self-referred for inpatient detoxification treatment completed with step down to inpatient rehabilitation and substance use disorder treatment. The inpatient stay was extended because the discharge date conflicted with the patient's methadone maintenance treatment program (MMTP). The patient underwent detoxification in order to address longstanding substance use disorders with alcohol and opioid class substances; he was also tobacco dependent with use of one pack per day for 25 years. The patient has no history of withdrawal seizures or delirium tremens, though he does have a history of seizures and is prescribed Depakote. He was referred due to difficulty with the social environment and coping problems related to the substance use disorders, and his inability to remain abstinent while participating in the methadone maintenance treatment program (MMTP) with medication assisted treatment of the opioid use disorder. He had substance use disorder treatment experience with a rehabilitation treatment episode earlier in the year, as well as detoxification treatment episodes also earlier in the year with relapse. His substance use included one-fifth of liquor per day together with three bags of heroin with intravenous (IV) administration. Again, his referral for treatment was prompted by the methadone maintenance treatment program (MMTP) where he was repeatedly found to have positive drug screens for opiates (heroin).

The patient has a history of psychiatric disorder best characterized as panic disorder and unspecified anxiety disorder, as well as chronic insomnia. He denied history of psychiatric hospitalization or suicidal behavior.

The patient has no acute general medical issues; he was medically screened upon admission with laboratory assessment and physical examination that were grossly normal or unremarkable. He had a remote history of seizures with use of Depakote. He was also tobacco dependent at one pack per day for 25 years, as noted.

The patient is homeless and unemployed with limited support from his aunt. There was no history of legal issues or trauma history in this case.

The patient's evaluation on admission revealed a mental status examination that reflected external motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. The patient was described as cooperative with fluent speech and organized thought processing. He displayed euthymic mood and diminished focus or concentration with no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal ideation or aggressive impulses. There were no significant withdrawal symptoms or post-acute withdrawal symptoms at the time of his step down/completion of detoxification or extension of inpatient level services.

Upon admission to inpatient level services, the patient received 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, as well as 12-step recovery groups and other therapeutic activities. Psychiatric evaluation was provided and affirmed that the patient had co-occurring psychiatric disorders, anxiety and panic disorder. The patient engaged in substance use disorder rehabilitation treatment. He was noted to participate in the therapeutic activities, was social with peers and was actively participating in recovery groups and adherent with medication that included vitamin supplements and the availability of nicotine replacement, as well as continued use of Depakote and Methadone at 60 milligrams (mg) daily, and as needed (PRN) use of Vistaril and trazodone to address anxiety and insomnia. He was sleeping and eating okay with steady gait and functioning with daily activities.

Throughout his extended inpatient stay, the patient remained stable with no withdrawal symptoms and engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged with recommendations for clinically appropriate aftercare of his substance use disorders including continued involvement in the methadone program. 

No, the inpatient admission was not medically necessary for this patient.

The patient presented with substance use disorders and was diagnosed with alcohol, opioid and tobacco use disorders. He self-referred and briefly received inpatient level rehabilitation treatment which was an extension of his detoxification that was completed. The patient readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted an inpatient level of care following the detoxification treatment. 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 brief inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted an inpatient level of care, structure or 24-hour monitoring. The application of NY (New York) State OASAS (Office of Alcoholism and Substance Abuse Services) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with a lower level of care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the inpatient admission is not met in this case scenario, consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had achieved a level of stability that included no significant withdrawal symptoms or biomedical issues and no co-occurring psychiatric disorders or safety concerns that would have warranted an inpatient level of care. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment and the patient was receiving medication assisted treatment with methadone at his usual dose of 60 milligrams (mg) daily. He readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports for living. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY (New York) State OASAS (Office of Alcoholism and Substance Abuse Services) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Guidelines/Criteria, referenced below.