Appeal type: Medical necessity
Decision: Upheld

Substance abuse/addiction
Substance abuse: Inpatient

The patient is referred for inpatient rehabilitation and substance use disorder treatment  to address opioid, stimulant (cocaine), and cannabis class substance use disorders. The patient was also using benzodiazepines requiring a Klonopin taper. The referral was prompted by  failure to remain abstinent following treatment with relapse and escalating use of substances. Also, the request for substance-related services was motivated by the desire to maintain a healthier lifestyle with respect to  family. In this case, the patient's substance use disorder treatment was interrupted with a brief inpatient psychiatric stay  with a readmission to the rehabilitation program in order to resume inpatient substance use disorder treatment.
The patient has a longstanding history of substance use disorder with multiple detoxification treatment episodes, as well as rehabilitation treatment. Patient was using up to six bags of heroin with  (IV) administration and $50 dollars worth of crack cocaine and one blunt of marijuana daily. Patient was also tobacco dependent. The patient has co-occurring mental disorders that include schizoaffective disorder-bipolar type, an unspecified anxiety disorder with panic attacks, and chronic posttraumatic stress disorder (PTSD). There is a history of psychiatric hospitalization and suicidal behaviors with the last admission six to eight months prior to his admission. Laboratory assessments were normal or unremarkable or negative, and drug screen was consistent with history. is not employed and lives with a non-relative. There were trauma related issues with regard to childhood abuse. Family history is positive for substance use disorder reflecting genetic predisposition. History of legal issues with incarceration for a felony assault, but no current legal problems. Evaluation on the re-admission revealed a mental status examination that reflected external and internal motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses with regard to bouts of anger and affective instability. The patient was described as groomed and cooperative with fluent speech and disorganized thought processing with tendency to ramble. Patient did not report suicidal ideation or aggressive impulses despite the recent inpatient mental health stay for extreme anger and affective instability.Throughout the readmission inpatient stay  the patient remained stable with regard to mental status and remained engaged with respect to the treatment regimen including focus on coping skills and the development of a relapse prevention plan. Patient received the continued treatment with intensive services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged with clinically appropriate aftercare and recommendations for continued involvement with recovery groups and return to his home community. The health plan determination is upheld in whole. During the time interval under review, the patient was noted to be in no apparent distress with satisfactory daily functioning and active participation in treatment including positive interactions with staff and peers. There were no emerging treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the inpatient level of care. The application of NY State OASAS LOCADTR Criteria did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting.