Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adult male. He presented for detoxification and withdrawal management. The patient has a history of severe substance use disorders beginning in early adolescence escalating to daily use of alcohol and cannabis (marijuana) class substances of abuse and intermittent use of cocaine. He has a 33-year history of substance use with five prior treatment episodes with relapse and no significant sobriety. He was using up to two pints of liquor on a continuous daily basis together with one marijuana joint and $20 worth of cocaine twice weekly with intranasal administration. The patient was single and homeless and unemployed with limited family support; he reported severe psychosocial stressors within the primary support, social environment, occupational, and housing domains. The patient reported functional decline as the substance abuse/disease had progressed, which prompted his self-referral for treatment of the comorbid substance use disorders. The patient has a history of psychiatric disorder and past treatment including one hospitalization for schizoaffective disorder, and no history of suicidal or self-harming behaviors. His Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score was eight in the mild range. The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins, as well as the availability of nicotine replacement for tobacco dependence and with the availability of counseling and comfort medications and prn (as needed) medications prescribed for pain, anxiety, and insomnia. He was discharged on Day #6 after completion of the detoxification protocol with direct transfer for rehabilitation services. The health plan denied coverage for the requested services based on New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria indicating that the patient could have been provided services with lower-level care such as residential treatment. The treatment facility indicated that the requested services were medically necessary in keeping with 
New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3 Guidelines for the treatment of substance use disorders. The appeal referenced the lack of a reasonable recovery environment or supports, high risk for relapse and high risk for medical complications of withdrawal in the context of the quantity and frequency and duration of substance use and no recent exposure to treatment, as well as a lack of insight and knowledge about a recovery process requiring motivational enhancement and efforts to address deficient coping skills.

The Inpatient Rehabilitation Admission was medically necessary.

The requested benefit of inpatient detoxification and substance-related treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring in an inpatient setting. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms that were being effectively addressed with a Librium protocol and supportive measures. Thus, the inpatient stay and detoxification treatment of this patient's substance use disorders did warrant the hospital admission and the continued structure of an inpatient level setting. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and New York State instruction for medical necessity reviews including the appropriate application of NY (New York) OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria.