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 male with diagnoses of alcohol use disorder (AUD), cocaine use disorder, benzodiazepine use disorder, and type 2 diabetes mellitus.  The question is whether inpatient rehabilitation treatment was medically necessary.

The patient's urine drug screen at the time of admission was positive for benzodiazepines and blood alcohol level was negative. Patient denied any history of SI (suicidal ideation) or HI (homicidal ideation). With regards to functional impairment, patient denied any difficulty with completing activities of daily living, reported that he has worked several jobs "off the books," and denies any legal history related to substance abuse. He reported that his family was supportive of his recovery.

During his inpatient rehab admission, patient's treatment included a medication regimen of comfort medications. A treatment plan lists a goal of establishing and maintaining total abstinence with objectives of developing coping skills to prevent relapse.  He continued to deny any safety concerns, SI/HI (suicidal ideation/homicidal ideation), or withdrawal symptoms throughout admission. Nursing notes indicate that the patient was alert and oriented throughout admission but frequently refused finger sticks and medications. It is noted that he did not bring his diabetes supplies with him to the facility.

The patient requested discharge against medical advice from the rehab facility, noting that he planned to return to his job. He planned to return home and it was noted that he has stable housing. He had an appointment for outpatient follow up to address his substance use disorder and vocational concerns. He was noted to be medically stable at the time of discharge, denied any withdrawal symptoms, and denied SI/HI (suicidal ideation/homicidal ideation), hallucinations, or any other severe psychiatric symptoms.

At issue is inpatient rehabilitation level of care for dates of service.  A physician reviewer used Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for Substance Abuse Inpatient Rehabilitation criteria for the determination and concluded that medical necessity for an inpatient rehab level of care was not met due to the patient's lack of acute withdrawal symptoms, unstable acute medical conditions requiring 24 hour care, lack of history of psychiatric diagnosis, having presented voluntarily for treatment, having left AMA (against medical advice) due to needing to get back to work, and having supports for sobriety. It was also noted that the patient was able to participate in or comply with treatment outside of a 24-hour strutted treatment setting, did not have social, emotional, or developmental barriers to participating in treatment outside of an inpatient level of care, did not have a co-occurring medical or psychiatric condition that required inpatient care, and was not experiencing symptoms or functional impairment that created an imminent risk of harm to self or others.  As such, it was noted that rehabilitative services in a residential setting were appropriate.

No, the Inpatient admission was not medically necessary.
The following is the patient's American Society of Addiction Medicine (ASAM) Patient Placement Criteria Rating:
(Dimension 1) Risk: 0-Individual is fully functioning with good ability to tolerate, cope with withdrawal discomfort-No signs or symptoms of withdrawal present-No signs or symptoms of intoxication.
(Dimension 2) Risk: 1-Demonstrates good ability to tolerate and cope with physical discomfort-Mild symptoms may interfere with daily functioning, but would likely not interfere with recovery treatment nor create risk.
(Dimension 3) Risk: 0-No current/chronic psychiatric, psychological, behavioral, emotional, or cognitive problems that create risk or complicate treatment.
(Dimension 4) Risk: 1-Willing to enter treatment and explore strategies for changing alcohol use.
(Dimension 5) Risk: 2-Impaired recognition and understanding of substance use relapse issues-Regular use of alcohol-Moderate use of drugs.
(Dimension 6) Risk: 0-Has a supportive environment or is able to cope with poor supports.

Based on patient's risk ratings, a lower level of care would have been appropriate for treating the patient's substance use disorders.

Additionally, the patient does not meet criteria for inpatient level of care using LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria. The patient was not experiencing a life-threatening medical condition or severe psychiatric crisis, was not experiencing significant functional impairment due to his substance abuse, and was not experiencing acute withdrawal symptoms from alcohol or benzodiazepines. He did not have a history of life-threatening withdrawal syndromes or withdrawal seizures. He was not experiencing a severe medical problem or serious psychiatric symptoms that needed to be managed in an inpatient rehab setting in order for treatment for his substance abuse to be effective. He did not endorse using substances in hazardous situations or in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. He did not have any personal or interpersonal skills deficits. He was not documented to have been exhibiting predatory behavior that would have likely caused harm to others in a congregate setting. He did not report strong cravings or urges to use that were unmanageable or behavioral or emotional instability that would require stabilization with medical oversight in a residential setting. Based on LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) guidelines, the patient could have been appropriately managed at the residential rehabilitation level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As noted above, the severity of patient's symptoms based on ASAM (American Society of Addiction Medicine) patient placement criteria and LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria show that the patient's condition could have been managed at a lower level of care than inpatient rehabilitation. There is no documentation of acute withdrawal symptoms, he did not have an acute medical condition that required inpatient treatment, and he did not endorse SI (suicidal ideation), HI (homicidal ideation), or any other severe psychiatric symptom that would require inpatient treatment. He also denied any history of any serious psychiatric diagnoses. He stated that he has a good sober support system at home and was willing to continue his treatment on an outpatient basis as evidenced by his upcoming follow up appointment.