Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse.
Treatment: Inpatient Admission.

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a adult male. He completed detoxification treatment and was admitted 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. He had past treatment experience with recent attempts at detoxification and rehabilitation treatment earlier in the year with an AMA (against medical advice) discharge and relapse. His substance use included two pints of liquor and $50 worth of crack cocaine use on a daily continuous basis.

The patient has a past history of psychiatric disorder including PTSD (post-traumatic stress disorder) and bipolar disorder with no recent treatment and no psychotropic medications. He 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 had completed detoxification treatment prior to admission and presented with residual withdrawal symptoms or post-acute withdrawal symptoms (PAWS) that included gastrointestinal upset and tremor.

The patient is single and unemployed and homeless. 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. 

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. 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 brief 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 against medical advice (AMA) and indicated that he would seek follow up treatment on his own.

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

The patient presented with substance use disorders and diagnosed with alcohol and stimulant/cocaine use disorders. He had completed detoxification treatment and received inpatient level rehabilitation treatment. The patient readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted an 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 brief inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted an inpatient level of care, structure or 24-hour monitoring. The application of NY (New York) State OASAS (Office of Alcoholism and Substance Abuse Services) 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 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, or to address post-acute withdrawal symptoms that had persisted. 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 State OASAS LOCADTR 3.0 Guidelines/Criteria, referenced below.