Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction - Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient
The health plan denied the inpatient substance abuse rehabilitation admission as not medically necessary. The health plan's determination is upheld in whole. 

The patient is a male who was admitted to inpatient level services for treatment of hallucinogen (phencyclidine [PCP]) and cannabis use disorder; the patient had been using up to one blunt of PCP and 10 blunts of marijuana per day with a longstanding history of PCP abuse and more recent use of marijuana. The patient self-referred for substance-related treatment and was reasonably motivated to enter substance abuse rehabilitation treatment indicating that he had experienced job loss due to the PCP use and wanted to reenter the workforce.
The patient had no acute general medical issues. The medical screening was negative and unremarkable except for a positive drug screen consistent with his history. He was tobacco/nicotine dependent with 20 years of use at 12 pack per day.

There are co-occurring psychiatric disorders in this case including post-traumatic stress disorder (PTSD) and unspecified depressive disorder with no current symptoms or treatment for these conditions. The patient is unemployed and housed and domiciled. There is a report of unspecified trauma history in this case. There are no legal issues in this case.
The Mental Status Examination revealed no severe symptoms, and the patient was pleasant, cooperative, and euthymic with normal speech, linear thought processing, and no disturbance of thought content such as paranoid thoughts or delusions. He lacked coping skills and demonstrated only fair insight. He reported urges to use PCP and marijuana and had been unable to cut down on his own. He was noted to have deficient coping skills and needed to identify triggers for his substance use.
The inpatient level substance disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education, and attendance at self-help recovery groups with peer support. Comfort medications were available as needed, and he was prescribed vitamins and had the availability of nicotine replacement.
The patient engaged in substance use disorder treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. The patient was noted to adjust easily to the treatment program. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including peer support to address the negative influence of the social environment. The patient remained engaged throughout the brief inpatient stay with satisfactory progress. However, the patient was discharged against medical advice with recommendation for clinically appropriate aftercare.
At issue is the medical necessity of the requested health service/treatment of substance abuse inpatient rehabilitation.
The health plan's determination of medical necessity is upheld in whole.
the requested health service/treatment of substance abuse inpatient rehabilitation admission was not medically necessary for this patient.
The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was reasonably motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or 24-hour nursing monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment.
Thus, the requested health service/treatment of inpatient substance abuse rehabilitation admission was not medically necessary for this patient.