Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder. 
Treatment: Substance Abuse Inpatient Rehabilitation. 
The insurer denied: Substance Abuse Inpatient Rehabilitation. 
The denial is upheld. 

The patient is an adult male. He was referred from residential treatment and admitted for inpatient rehabilitation substance use disorder treatment in order to address severe alcohol use disorder. The history of substance use included use of six 24-ounce beers twice weekly. He was failing his urine toxicology assessments while in the residential program. The patient has a history of psychiatric disorder best characterized as bipolar disorder with depression and anxiety but denied psychiatric hospitalization or suicidal behavior. He had no other substance use disorders but was tobacco dependent. There were no acute general medical issues; he was medically screened at the time of admission. Vital signs were normal and laboratory assessments were normal or unremarkable including a negative drug screen. 
The patient's evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. 
The patient readily engaged in substance use disorder rehabilitation treatment. The patient was noted to be engaged in the therapeutic activities, social with peers, and participating in recovery groups and most other group sessions. He was adherent with medication that included the vitamin supplements and comfort medications, as noted. He continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring, and was discharged after completion of inpatient rehabilitation treatment with referral back to his residential program. During the time interval under review, the patient had no significant withdrawal or post-acute withdrawal symptoms, no safety concerns, and no psychiatric or biomedical complications. The health plan's denial of coverage is based on New York State Office of Addiction Services and Supports Level of Care for Alcohol and Drug Treatment Referral (OASAS LOCADTR) 3 Criteria and medical necessity. 

The Substance Abuse Inpatient Rehabilitation was not medically necessary. 

The health plan's determination is clinically appropriate in keeping with prevailing standards of medical practice. In this case, the patient could have been reasonably managed with lower-level care in a less restrictive treatment setting, as the health plan asserted. The patient presented with substance use disorder, diagnosed with severe alcohol use disorder. He was medically screened and had no acute general medical issues. He received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues, as well as receiving motivational enhancement and consideration of the use of medication assisted treatment and ongoing vitamin replacement therapy. Throughout his stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues or safety concerns that would have warranted inpatient level of care, structure, or 24-hour monitoring for the time interval under review. The application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria, as well as Level of Care Utilization System (LOCUS) and American Society of Addiction Medicine (ASAM) 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.