Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Detoxification Admission. 

The insurer denied the Inpatient Detoxification Admission. 
The denial is upheld. 

The patient is an adult male. He self-referred for inpatient rehabilitation and substance use disorder treatment. The patient has a history of longstanding substance use disorder with cocaine. The patient has no history of withdrawal seizures or delirium tremens. He indicated difficulty with the social environment with peers using substances of abuse and coping problems related to the substance use disorder which had adversely impacted his health and functioning. His history of substance use included up to $100 worth of cocaine on a daily continuous basis. He denied use of other substances except for tobacco. 

Throughout his inpatient stay, the patient remained stable with mental status and engaged with the treatment regimen, as noted. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged with plans for clinically appropriate aftercare of his substance use disorders with referral for outpatient services and return home. 

The health plan denied coverage of the patient's stay on the basis of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria indicating that there were no acute symptoms that would have required inpatient level services and suggesting that lower-level treatment was the appropriate level of care. The denial determination indicated that the patient had no safety concerns or general medical problems requiring inpatient level care, and was motivated with community supports available. 

The treatment facility appealed on the basis of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria indicating that inpatient level treatment was the appropriate level of care, as the patient lacked coping skills and needed to work on a relapse prevention plan with identification of triggers. Additionally, the appeal referenced that high risk for relapse, the lack of an adequate recovery environment, severe malnourishment with weight loss due to the use of cocaine, and the treatment for the abscess that required referral to a hospital. 

No, the requested Inpatient  Detoxification Admission including rehabilitation treatment was not medically necessary for this patient. 

The patient presented with substance use disorders, diagnosed with stimulant/cocaine and tobacco use disorders. He self-referred and received inpatient level rehabilitation treatment and other medical services. He readily engaged in treatment and had no biomedical or psychiatric treatment issues or safety concerns that warranted inpatient level care. During the time interval under review, the patient was noted to be in no apparent distress other than the presence of chronic pain and an abscess that responded to treatment. He demonstrated with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his inpatient stay, there were no serious complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring, as the health plan asserts in the denial determination. 

The application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria (referenced below and in the appeal and denial) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting. Thus, medical necessity for the Inpatient substance use disorder treatment is not met in this case scenario, consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below, and with the application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines pertaining to the appropriate level of care. 

Yes, the health plan has acted reasonably, with sound medical judgment and in the best interest of the patient. 

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient did not present with a level of medical stability or with co-occurring psychiatric disorders, comorbid medical problems, or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment, as the health plan asserts. He readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living. Thus, the health plan's determination is reasonable in this case scenario. 

This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Guidelines.