Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient rehabilitation
The insurer denied the inpatient rehabilitation.
The denial is upheld. 

No, the proposed treatment and the requested benefit of Inpatient substance abuse rehabilitation treatment is not medically necessary for this patient.

The patient is a male referred for inpatient rehabilitation and substance use disorder treatment in order to address use of alcohol, sedative-hypnotic-anxiolytic (Xanax), and stimulant (cocaine) class substances. The patient has no reported history of withdrawal seizures or delirium tremens. His history of substance use included use of one twelve pack of beer daily, $20 to $100 worth of cocaine daily with intranasal administration and use of up to two milligrams (mg) of Xanax daily. The patient has a history of multiple prior treatment episodes with relapses. He was admitted/transferred for rehabilitation treatment following detoxification treatment.

The patient has a history of psychiatric disorder best characterized as an unspecified mood disorder with insomnia treated with Seroquel. There was no history of psychiatric hospitalization or suicidal or self-harming behavior. He had no acute general medical issues; he was medically screened upon admission. Chronic conditions included dyslipidemia treated with a statin. He was tobacco dependent.

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 continued with Seroquel, as well as vitamin and nicotine replacement therapy, and as needed (PRN) Vistaril for anxiety. The patient readily engaged in substance use disorder rehabilitation treatment. He briefly received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. At his request, the patient was discharged with transfer to another rehabilitation facility for continued and clinically appropriate care of his substance use disorders.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and sedative hypnotic anxiolytic use disorders. He had received detoxification treatment. He was medically screened and had no acute general medical issues. He received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or psychiatric treatment issues with continued use of Seroquel for an unspecified mood 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 his brief 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 State OASAS LOCADTR 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 rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.