Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Use Inpatient Rehabilitation Treatment:
The insurer denied: Substance Use Inpatient Rehabilitation Treatment:
The denial is upheld.

The patient is an adult female who received detoxification treatment and was referred for inpatient rehabilitation substance use disorder treatment in order to address use of alcohol and stimulant (crack cocaine) class substances. The patient has no 
reported history of withdrawal seizures or delirium tremens though there was a history of severe withdrawal symptoms in the past during detoxification treatment and frequent blackouts. The patient was referred by her counselor for treatment and indicated that she was tired of feeling unwell. She had an extensive history of detoxification treatments and rehabilitation treatment with relapses. The patient has a history of psychiatric disorder and treatment for bipolar disorder and presented without severe symptoms of depression or anxiety. The patient has no history of psychiatric hospitalization or suicidal behavior or attempts.
The patient is married and unemployed with social security income and domiciled with family. She has two children with support and indicated that she had family support. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. Psychiatric evaluation was provided, and she was prescribed Depakote and Seroquel with as needed (PRN) use of Benadryl or trazodone for insomnia/sleep. Other medications included a rescue inhaler, Symbicort and Flovent with a course of antibiotics, analgesics including Montelukast, hydrochlorothiazide (HCTZ), and other comfort drugs, as well as vitamin replacement therapy. The patient readily engaged in substance use disorder rehabilitation treatment. The patient was noted to be engaged in the therapeutic activities, social with peers and participating in recovery groups and most other group sessions, and adherent with medication that included the vitamin supplements and comfort medications and scheduled medications as noted, as well as medication assisted treatment with naltrexone to address cravings. She continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring and was discharged with referral for clinically appropriate care of the mental health and substance use disorders.  The patient had remained abstinent from substances, and she was motivated for treatment and committed to continue with a recovery process and rehabilitation treatment.
The denial of coverage is based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and medical necessity indicating that there were no general medical or psychiatric issues warranting 24-hour nursing care and that treatment could have been provided in a less restrictive treatment setting.
The appeal was on the basis of the clinical features and treatment dimensions with reference to the psychosocial stressors and lack of coping skills with no stability or structure or sober supports warranting the inpatient level rehabilitation treatment.

The proposed treatment is not medically necessary.

The patient could have been reasonably managed with lower-level care in a less restrictive treatment setting. The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use disorders. She received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues. She resumed treatment for the co-occurring psychiatric disorder-bipolar disorder, depressed phase in the context of past non-compliance with her psychotropic medications.