Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis use disorder.
Treatment: Inpatient chemical dependency rehab stay.
The insurer denied inpatient chemical dependency rehab stay.
The determination is upheld.

The patient was to inpatient level services for treatment of cannabis use disorder; the patient had been using up to 3 blunts of marijuana per day in violation of his parole. The patient was referred for substance-related treatment after testing positive for tetrahydrocannabinol (THC); he also tested positive for phencyclidine (PCP) and cocaine though he denied use of these substances. The patient was externally motivated to enter substance abuse rehabilitation treatment in order to comply with his parole officer's recommendation.
The patient has no acute general medical issues. He is diagnosed with asthma treated with a rescue inhaler. Medical screening was negative and unremarkable except for a positive drug screen. He was tobacco/nicotine dependent with 13 years of use at a 12 pack per day. There are no co-occurring psychiatric disorders in this case.
The patient is unemployed and housed and undomiciled. He is on parole, as noted, and in jeopardy with regard to violating the terms of his parole. There is a report of unspecified trauma history in this case.
Mental Status Examination revealed no severe symptoms and the patient was pleasant, cooperative and euthymic with normal speech, linear thought processing and no disturbance of thought content such as paranoid thoughts or delusions. He lacked coping skills and demonstrated only fair insight.
The inpatient level substance disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education and 12-step recovery groups with peer support. Comfort medications were available as needed, and he was prescribed vitamins.
The patient engaged in substance use disorder treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. The patient was noted to adjust easily to the treatment program. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including peer support to address the negative influence of the social environment.
The patient remained engaged throughout the inpatient stay with satisfactory progress. The patient was administratively discharged for rules violation.
Case records and the health plan documents, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's rationale for denial of the requested inpatient rehabilitation services were reviewed. This is a New York State mandated review including the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.

At issue is the medical necessity of inpatient chemical dependency rehabilitation (rehab) stay.
The requested health service/treatment of inpatient chemical dependency rehab stay was not medically necessary for this patient.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services and, the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and 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 inpatient level services and treatment.
This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and scientific literature, referenced below, as well as the NY State OASAS LOCADTR 3.0 Criteria, referenced below and applicable in this case.