Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorders
Treatment: Inpatient admission for substance use disorder rehabilitation treatment.
The insurer denied the inpatient admission for substance use disorder rehabilitation treatment. 
The denial is upheld. 

The patient is a adult male. He self-referred for inpatient rehabilitation and substance use disorder treatment to address longstanding substance use disorders with alcohol and stimulant (crack cocaine) class substances with onset of alcohol use disorder in early adolescence and progression to the use of cocaine. The patient has no history of withdrawal seizures or delirium tremens. He was referred due to difficulty with the social environment and coping problems related to the substance use disorders, and with the encouragement of family and friends. He had limited treatment experience with recent attempt at detoxification with relapse. His substance use included two pints of liquor and $50-75 worth of crack cocaine use on a daily continuous basis.

The patient has no history of psychiatric disorder and 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. He has type II diabetes mellitus and tinea pedis with associated treatments including prescribed insulin while in rehabilitation treatment. He had completed detoxification treatment prior to admission and drug screen was consistent with history, with only cocaine and benzodiazepine showing positive. He presented with no residual withdrawal symptoms or post-acute withdrawal symptoms (PAWS).

The patient is single and unemployed and lives in an apartment. Peers were using substances of abuse, a negative influence. 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 euthymic 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.

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 no co-occurring psychiatric disorders. 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 and the availability of comfort medications. He was sleeping and eating okay with steady gait and functioning well with daily activities.

Throughout his inpatient stay, the patient remained stable with no withdrawal symptoms and engaged with the treatment regimen. 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 with recommendations for clinically appropriate aftercare of his substance use disorders and a primary care appointment for continued management of the diabetes mellitus.

No, the requested inpatient admission for substance use disorder rehabilitation treatment is not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use disorders. He self-referred and received inpatient level rehabilitation treatment following detoxification 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 Addiction Services and Supports) 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 for the inpatient admission for substance use disorder rehabilitation treatment is not met in this case scenario, 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 co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. 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. 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 Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Guidelines/Criteria, referenced below.