Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance  Abuse/Addiction.
Treatment: Substance  Abuse Inpatient.
The insurer denied the Substance Abuse Inpatient stay.
The health plan's determination is upheld in whole. 

The inpatient substance abuse admission was not medically necessary for this patient. The patient is an adult  who received inpatient rehabilitation substance use disorder treatment of opioid (heroin) use disorder; the patient had been using 3 bags of heroin per day with intravenous (IV) administration, and history of use of up to 20 bags of heroin in the past. Patient was also tobacco dependent at one-half pack per day. The referral was prompted by a decline in functioning with severe psychosocial stressors involving the primary support (family), occupational, housing, economic and social environment domains. The patient had acute general medical issues with infection at the injection sites and antibiotic treatment. Chronic medical conditions included hepatitis C positivity and musculoskeletal pain addressed with gabapentin and analgesics. Medical screening at the time of admission was negative and unremarkable except for a drug screen consistent with history. The patient denied the current use of other substances of abuse.
There are co-occurring psychiatric disorders in this case with unspecified anxiety disorder and bipolar mood disorder with the most recent episode depressed, and a history of at least one psychiatric hospitalization in the past. The patient was prescribed olanzapine and mirtazapine for his mental disorders, as well as the gabapentin, muscle relaxers and Benadryl to address insomnia. The patient was admitted to inpatient rehabilitation treatment with inpatient level substance use disorder rehabilitation treatment including the opportunity to participate in groups, individual counseling, education, and 12-step recovery groups with peer support. Comfort medications were available as needed, and patient was prescribed vitamins with the availability of nicotine replacement therapy. Patient was continued on psychotropic medications in order to address psychiatric disorders. The clinical course was benign, and patient engaged with treatment. The patient was discharged against medical advice with recommendations for continued substance use disorder rehabilitation services and continued treatment for general medical co-morbidity and co-occurring psychiatric disorders.
The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be and could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome in this case. And, there were no biomedical, psychiatric, or general medical issues that warranted the admission for inpatient level treatment.
The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was generally motivated and capable of effectively engaging in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure or 24-hour monitoring of an inpatient setting in order to participate in rehabilitation substance abuse treatment safely and effectively. This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, as well as New York State instruction for medical necessity reviews together with the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below and applicable in this case.