Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He self-referred for inpatient rehabilitation and substance use disorder treatment to address longstanding substance use disorder with alcohol with onset of alcohol use disorder in early adolescence and progression to severe alcohol use disorder. The patient has no history of withdrawal seizures or delirium tremens, and he denied blackouts. He was referred due to a relapse after seven to eight years of sobriety with use of up to one-fifth of vodka per day. He had treatment experience with a recent attempt at detoxification earlier in the year with relapse.

The patient has no history of psychiatric disorder other than depression that had not been treated, and 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 including a negative drug screen. He had a history of arthritis and sciatica treated with ibuprofen and indicated that his pain was at a 3 of 10 level. He presented with no residual withdrawal symptoms or post-acute withdrawal symptoms (PAWS). The patient was tobacco dependent at 14 pack per day use.

The patient is single and unemployed and lives in a homeless shelter. There was no history of legal issues or trauma history reported in this case.

The patient's evaluation on admission revealed a mental status examination that reflected reasonable 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 mildly depressed 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-as noted. The patient had pain due to arthritis and sciatica, as noted, and chronic insomnia.

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 a diagnosis of unspecified depressive disorder with mild symptoms. 

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, melatonin and Benadryl, and ibuprofen, as well as nicotine replacement therapy and the availability of comfort medications. He was sleeping with the use of medications, and he was eating okay with steady gait; and the patient was functioning well with daily activities throughout his stay.

Throughout his inpatient stay, the patient remained stable with no withdrawal symptoms and he readily engaged with the treatment regimen after the first week. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged with referral to a sober living house (group residential for the homeless) with recommendations for clinically appropriate aftercare of his substance use disorders and a primary care appointment for continued management of the chronic pain and arthritis and sciatica.

No, the Inpatient Rehabilitation Admission and Treatment was not medically necessary for this patient.

The patient presented with a relapse of severe alcohol use disorder. He self-referred and received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. 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 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 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 lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity is not met for the Inpatient Rehabilitation Admission and Treatment for this patient. This answer is also 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 presented with a level of stability that included no significant withdrawal symptoms or biomedical issues and no severe co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care and safety monitoring. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder rehabilitation treatment. He readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been effectively provided in a less restrictive treatment setting with sober supports or living. Thus, the health plan's determination is reasonable in this case scenario and the denial of coverage for inpatient level treatment was issued with sound medical judgment. 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.