Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Rehabilitation
The insurer denied the Inpatient Substance Abuse Rehabilitation.
The determination is upheld.

The patient presented requesting detoxification treatment and completed detoxification treatment with transfer for inpatient rehabilitation substance use disorder treatment to address substance use disorder with stimulants (cocaine); alcohol; and opioids (heroin), as well as use of Klonopin together with alcohol. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior treatments with relapses no substantial periods of sobriety in the past. He was using cocaine at approximately $50 per day; and, daily use of alcohol with up to two pints of vodka; and, opioids with up to 20 bags of heroin, as well as six Klonopin tablets per day or intermittently. His use of heroin was in spite of being in an outpatient treatment program with medication assisted treatment with Suboxone.
His substance use had escalated over a several year time frame and was associated with significant decline in functioning and other consequences within social, occupational, and primary support domains. The patient had previously engaged in substance use disorder treatment and the last treatment episode had occurred immediately prior to his presentation to an emergency department.
The patient provided a history of a psychiatric disorder and treatment for mood and anxiety disturbance treated with Effexor, Seroquel and Klonopin. There was a history of multiple psychiatric hospitalizations. His diagnoses included major depressive disorder and unspecified anxiety disorder.
There were no acute general medical issues in this case. The patient has chronic conditions including obesity and hepatitis C positivity. He was tobacco dependent. He had been medically screened at the time of his admission for detoxification and substance-related treatments.
Evaluation on admission for inpatient level services revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for rehabilitation treatment. The patient was described as cooperative with fluent speech and anxious or dysphoric mood, and, diminished focus or concentration with limited insight with regard to the substance use disorder. He had no evidence of acute mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal or homicidal ideation.
The patient is single and unemployed and homeless. He was estranged from his ex-girlfriend and minor child. He has limited social support and coping skills. There were no prominent legal issues or trauma history in this case.
The patient was admitted to inpatient rehabilitation treatment following detoxification with continued use of Suboxone and replacement of vitamins and nicotine. He 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 and individual therapy, as well as 12-step recovery groups and other therapeutic activities. Psychiatric evaluation was provided and he was prescribed/continued with his usual psychotropic medications including medication assisted treatment with Suboxone.
Throughout the brief inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the inpatient substance use disorder treatment program. The patient had no severe withdrawal symptoms or post-acute withdrawal symptoms. The patient was participating actively in treatment, and had no complications with respect to biomedical, general medical, emotional or other treatment domains. Mental status examinations/progress notes reflected stable mood with sleep, appetite and energy that were okay. However, he threw a glass of water on another patient on the day of discharge resulting in an administrative discharge with referral for clinically appropriate aftercare and continuation of his prescribed medications.
The health plan documents, appeal documents, and correspondence from the health plan and treatment facility, as well as case records and summary, and the health plan's case notes, and, the health plan's rationale for the denial of certification for coverage of the requested treatment, were reviewed. This case is a New York State mandated review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria.
At issue is the medical necessity of Inpatient Substance Use Disorder Rehabilitation Services.
The requested health service/treatment of Inpatient Rehabilitation is not medically necessary for this patient.
The patient presented with substance use disorders with use of heroin, alcohol and cocaine while participating in medication assisted treatment with Suboxone. He received inpatient detoxification treatment transitioning to inpatient level rehabilitation treatment. He readily engaged in treatment with continued use of Suboxone and his medications to address mood and anxiety disorders with tolerability and adherence. During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers until the day of discharge. The application of NY State 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, as the health plan asserts. Thus, medical necessity for the admission and the continued Inpatient stay is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.