Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse disorder. 
Treatment: Substance Abuse Inpatient Rehabilitation Admission. 

The insurer denied: Substance Abuse Inpatient Rehabilitation Admission. 
The denial is upheld. 

The patient is a female who was admitted for inpatient rehabilitation substance use disorder treatment in order to address substance use disorder with alcohol, opioid, and cocaine class substances of abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She had a history of substance use disorder with multiple prior detoxification/rehabilitation treatments and participation in a methadone maintenance treatment program with relapses or continued use of heroin, cocaine and small amounts of alcohol. She reported daily use of five bag of heroin with snorting, and three bags of cocaine powder with smoking. She was also tobacco dependent with daily use or a quarter pack. 

The patient was admitted to inpatient rehabilitation treatment with replacement of vitamins and comfort medications, as well as continued use of methadone at 60 milligrams (mg) per day. She was provided 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 peer-supported 12-step recovery groups and other therapeutic activities. The program utilizes motivational techniques, cognitive behavioral therapy (CBT) and other psychosocial interventions. The patient was discharged with plans to immediately return to outpatient level treatment with the methadone program and with recommendation for involvement in recovery groups. 

The health plan's determination is upheld. 

The requested health service/treatment of Substance Abuse Inpatient Rehabilitation Admission was not medically necessary for this patient. 

The patient in this case scenario is not clinically appropriate for the inpatient rehabilitation level of care during the time interval under review. The patient did not need the intensity or duration or 24-hour monitoring of an inpatient level of care. The patient was motivated with fair insight, and readily engaged with treatment including involvement with peer supported recovery groups while continuing medication assisted treatment with methadone. 

The patient presented with substance use disorders with use of alcohol, opioid and cocaine class substances while participating in a methadone maintenance treatment program. She readily engaged in treatment with continued use of methadone and comfort medications. During the time interval under review, the patient was noted to be in no apparent distress with active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted the admission or continued inpatient level of care. The application of Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting.
Medical necessity is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below, as well the application of OASAS LOCADTR Criteria.