Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to an inpatient rehabilitation for substance use disorder and treatment of opioid (heroin) and stimulant (cocaine) use disorders. The patient was using four bags of heroin on a daily basis with intranasal administration and was using $10-20 worth of cocaine one to two times per week. The patient reported use of these substances for approximately four to five months. The use of heroin was causing significant risk to the patient's health and impairing the patient's ability to function. The patient had completed a five-day detoxification treatment episode immediately prior to the admission for inpatient level substance use disorder rehabilitation treatment.
The patient has no acute or chronic general medical issues that were a focus of treatment. The patient's laboratory assessment and physical examination were normal or unremarkable, and the patient had been medically cleared for substance use disorder treatment.
The patient was a Desert Storm Veteran with a diagnosis of post traumatic stress disorder (PTSD) with no report of treatment for this condition. There are no other co-occurring psychiatric disorders in this case other than a history of insomnia associated with the PTSD. The patient denied psychiatric hospitalization or suicidal behavior. The patient denied history of severe withdrawal symptoms such as delirium tremors or withdrawal seizures, or history of overdose.
The mental status examination revealed a cooperative patient with clear speech and linear thought processing that was goal directed. The patient's thought content included no morbid thoughts. The patient's insight was fair with impaired judgment due to the addiction and poor control of impulse to use due to cravings. There were no severe symptoms such as mood disturbance, psychosis, cognitive impairment or perceptual disturbances, or suicidal ideation or aggressive impulses. There were no somatic concerns other than insomnia.
The patient is housed, unemployed and lives with family. The patient has a history of PTSD and is a combat veteran, as noted, and reported having a service animal.
The residential level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions and recovery groups with peer support. The patient engaged with rehabilitation treatment and actively participated in individual, group and educational sessions. The patient had comfort medications and vitamin replacement therapy, as well as the opportunity for smoking cessation education.
Discharge planning occurred with plans for continued intensive substance use disorder treatment, and involvement in recovery groups with sober supports and use of a relapse prevention plan. However, the patient interrupted the treatment and left against medical advice indicating the need to check on the patient's service animal. During the brief stay, there were no biomedical complications and the patient's course of treatment was benign.
The case records and the health plan documents, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's case notes and the rationale for denial of the requested inpatient rehabilitation services were reviewed.
At issue is the medical necessity of the inpatient substance use disorder rehabilitation services.

The health plan's determination of medical necessity is upheld.The patient's substance use disorder rehabilitation service was amenable to treatment at a lower level of care. The patient was motivated and capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure or monitoring of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to participate in peer-supported recovery groups or receive other evidence-based treatment such as medication assisted treatment.
Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission of the continued inpatient level services and treatment, as requested.