Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Rehabilitation Services. 

The insurer denied: Inpatient Rehabilitation Services. 
The denial is upheld. 

The patient is an adult male self-referred through his employer and admitted for inpatient rehabilitation and substance use disorder treatment in order to address use of stimulant (cocaine) and cannabis (marijuana and hashish) class substances. The patient has no reported history of withdrawal seizures or delirium tremens, or severe withdrawal symptoms. His history of substance use included use of up to $100 worth of crack cocaine and $50 worth of marijuana or hashish on a daily basis. The patient was medically screened upon admission including laboratory testing that was normal or unremarkable and drug screening that was positive for cocaine. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, and fair to good insight and judgment. He had no severe symptoms such as mania or depression, 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 peer supported recovery groups and other therapeutic activities within the treatment milieu. Psychiatric evaluation was provided and he was prescribed vitamins with the availability of nicotine replacement therapy, and comfort meds that included melatonin and Benadryl. The patient completed the rehabilitation treatment and was discharged with recommendations and referrals for continued and clinically appropriate aftercare of the substance use disorders with return home with family support. 
The health plan denied coverage of the stay on the basis of the New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria/Guidelines indicating that the criteria for inpatient level treatment was not met. The treatment facility asserted that LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria were met on the basis of the longstanding use of multiple substances and the patient's need for monitoring and the structure of an inpatient rehabilitation setting. 

The Inpatient Rehabilitation Services were not medically necessary. 

The patient presented with substance use disorders, diagnosed with cannabis and stimulant/cocaine use disorders. The patient readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or acute psychiatric treatment issues or past history of psychiatric disorder. 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 the 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 (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan asserted. Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines.