Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder
Treatment: Substance Abuse Inpatient Rehabilitation
The insurer denied Substance Abuse Inpatient Rehabilitation.
The health plan's denial is upheld. 

The patient is an adult male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine), alcohol, and cannabis (marijuana) use disorders, as well as early remission for opioid (heroin) use disorder. The patient was using two grams of crack cocaine and one marijuana joint daily together with three beers. The patient was also tobacco dependent with light use. He had a longstanding history of poly-substance use disorder with past substance use disorder treatment episodes, as well as three instances of incarceration off parole ten years.
The patient had no acute general medical issues that were a focus of treatment other than a tooth infection treated with antibiotics. The patient was medically cleared at the time of admission with laboratory assessments and an electrocardiogram (EKG), and he had a positive drug screen for cocaine, as well as Fentanyl and buprenorphine. There was a report of co-occurring psychiatric disorders in this case including post-traumatic stress disorder (PTSD) related to childhood verbal abuse and anxiety disorder with panic attacks.
Mental status examination revealed a cooperative but angry male with clear speech and linear thought processing that was goal directed. His mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. Insight was limited with impaired judgment due to the addictions. He had sleep disturbance with insomnia.
The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and recovery groups with peer support. The patient easily engaged in rehabilitation treatment. He actively participated in individual, group, and educational sessions including anger management. He was prescribed vitamins with the availability of nicotine replacement therapy throughout his stay, as well as comfort medications and consideration of medication assisted treatment. He declined psychiatric consultation.
Discharge planning occurred that included recommendation for continued aftercare with transfer to sober living upon completion of the program. The patient was cooperative and engaged throughout his inpatient stay with reasonable motivation and participation in therapeutic activities. There were no psychiatric or biomedical complications during his stay with discharge.
At issue is the medical necessity of Substance Abuse Inpatient Rehabilitation.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Substance Abuse Inpatient Rehabilitation was not medically necessary for this patient.
There is no documented evidence that the inpatient level structure and 24-hour nursing monitoring was medically necessary for a successful outcome in this case. The inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with clinically appropriate structure, monitoring and sober supports. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment. Thus, the requested benefit of inpatient substance use disorder rehabilitation services was not medically necessary for this patient.