Appeal type: Medical necessity
Decision: Upheld

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

The patient was transitioned from detoxification treatment to inpatient substance use disorder rehabilitation treatment to continue to address substance use of stimulants (crack cocaine); cannabis (marijuana); tobacco, and alcohol. The patient had no past history of withdrawal seizures, delirium tremens or severe withdrawal symptoms. She had a history of substance use disorder with onset in adolescence with cannabis with use of cocaine and alcohol as a young adult escalating to daily continuous use and a decline in functioning. She was using one to two pints of liquor daily together with $20 worth of crack cocaine and marijuana with daily use. Her substance use had resulted in psycho-social problems including unemployment. She self-referred to substance use disorder treatment with medical clearance and detoxification treatment prior to a step down for inpatient rehabilitation substance use disorder treatment.
The patient had previously engaged in substance use disorder treatment with a chronic relapsing clinical course. She had received multiple detoxification treatments in the past, as well as rehabilitation treatment episodes with relapse and no involvement in recovery groups.
There was a history of a psychiatric disorder and treatment for depressive disorder. She denied a history of psychiatric hospitalization or suicidal or self-harming behaviors. The patient had no acute general medical conditions. Chronic conditions included low back pain and headache. The patient was married and unemployed and lived with spouse. There was no report of trauma history or legal issues.
The patient exhibited limited insight and impaired judgment with questionable control of impulses. There were no severe symptoms on mental status examination; the patient had no symptoms of severe depression, mania, psychosis, perception, cognition, or thought disorder. She reported sleep disturbance and anxiety, but no other somatic symptoms.
The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction and involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the inpatient treatment program. The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment other than an altercation with her roommate requiring staff intervention. She received vitamin replacement therapy and comfort medications for anxiety, insomnia, pain and gastrointestinal symptoms. The patient participated actively in therapy. She was actively participating in treatment with treatment plans to address coping skills and to develop a relapse prevention plan and sober supports. She had no other complications during her stay with plans for continued outpatient substance use disorder treatment and recommendations for involvement in peer-supported recovery groups.
The treatment facility case records and summary, health plan documents, appeal documents, correspondence from the health plan and treatment facility, and the health plan 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.
The issue under review is the medical necessity of Inpatient Admission.
The requested health service/treatment of Inpatient Admission is not medically necessary for this patient.
The Inpatient Substance Use Disorder Rehabilitation Treatment was amenable to treatment at a lower level of care in a less restrictive treatment setting. The patient was motivated and able to effectively engage in rehabilitation services, and, the patient did not need the continued structure or monitoring of an inpatient setting or the intensity of therapy and inpatient level services in order to effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required continued inpatient level behavioral health and substance-related services. Moreover, the patient had not residual withdrawal symptoms and she was motivated to participate in rehabilitation treatment. Thus the Inpatient Substance Use Disorder Rehabilitation Treatment was not medically necessary for this patient.
This answer is consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as the NY State OASAS LOCADTR 3.0 Guidelines/Criteria, referenced below.