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. He was referred for inpatient rehabilitation and substance use disorder treatment beginning to address alcohol, cannabis (marijuana), and stimulant (cocaine) class substances. The patient has no reported history of withdrawal seizures or delirium tremens. His history of substance use included use of one six pack of beer up to three times per month, 40 dollars worth of cocaine daily, and five marijuana blunts daily. The patient has a history of two prior treatment episodes with relapses and was self-referred in the context of legal issues and homelessness with limited family support. The patient is single and employed. He lives with family and indicates that he has four children. There were reported legal issues with a pending court date for reckless driving, and no trauma history in this case. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. 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 peer-supported recovery groups and other therapeutic activities within the treatment milieu. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged on day #10 against medical advice with clinically appropriate recommendations for aftercare of his substance use disorders. The patient declined aftercare referrals. The denial of coverage was based on medical necessity and New York Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria/Guidelines indicating that the patient had no general medical or psychiatric issues warranting inpatient level care and had no severe or complicated withdrawal symptoms or history. 

The proposed treatment and the requested benefit of inpatient substance abuse rehabilitation treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol, stimulant/cocaine, and cannabis use disorders. He tested positive for cocaine and cannabis consistent with history. 
He was medically screened and had no general medical issues. He received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or psychiatric treatment issues and did not have a diagnosed psychiatric disorder. 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 inpatient level of care, structure, or 24-hour nursing monitoring. The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 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 for the inpatient substance abuse rehabilitation treatment is not met in this case scenario, also consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below.