Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Use Disorder
Treatment: Inpatient Admission
The insurer denied Inpatient Admission.
The determination is upheld.

The patient is an adult male who was admitted for inpatient rehabilitation substance use disorder treatment. 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 prior treatments and more recent participation in a methadone maintenance treatment program with continued use of substances. 
The patient has no history of psychiatric disorder or suicidal behavior. The patient reported that he was not taking psychotropic medications.
There were no acute general medical issues in this case; the patient had been medically screened at the time of his admission for substance-related treatments, and generally had normal vital signs and no severe withdrawal or post-acute withdrawal symptoms though he reported cravings and urges to use substances. He was an every-day smoker and tobacco dependent.
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 admitted to inpatient rehabilitation treatment with replacement of vitamins and comfort medications, as well as continued use of methadone. 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, as well as peer-supported recovery groups and other therapeutic activities.

The requested health service/treatment of substance use inpatient rehabilitation treatment was not medically necessary for this patient.
The patient presented with substance use disorders with use of opioid and cocaine class substances while participating in a methadone maintenance treatment program. He was admitted to inpatient level rehabilitation treatment. He readily engaged in treatment with continued use of methadone and comfort medications, as well as vitamin replacement therapy. During the time interval under review, the patient was noted to be in no apparent distress with active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted the admission or the continued inpatient level of care. The application of New York State Office of Addiction Services and Supports Level of Care for Alcohol and Drug Treatment Referral (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.
The patient in this case scenario is not clinically appropriate for the inpatient rehabilitation level of care during the time interval under review. The patient did not need the intensity or duration of treatment provided or the 24-hour nursing staff monitoring with an inpatient level of care. The patient was motivated and engaged with treatment and involved with peer supported recovery groups while continuing medication assisted treatment with methadone.