Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient rehabilitation-Chemical Dependency
The health plan denied the Inpatient chemical dependency rehabilitation stay as not medically necessary. 

The patient was admitted to inpatient rehabilitation substance use disorder treatment to address substance use disorder with stimulants (methamphetamine); cannabis, alcohol; and opioids (heroin). The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms, but did report an inadvertent overdose. The patient had a history of substance use disorder treatment with  most recent prior treatments following the overdose (detoxification only) and detoxification treatment with relapses. The patient was using one and one-half pints of liquor plus beer on a daily basis, and $60 worth of methamphetamine together with a small amount of heroin with intranasal (snorting) administration up to three times per week, and also reported intermittent use of marijuana/cannabis. Substance use had escalated with significant decline in functioning and other consequences within social, occupational, and other psychosocial domains. The patient has no history of psychiatric disorder or treatment. There was no history of psychiatric hospitalization or suicidal or self-harming behavior. The patient had normal vital signs and no severe withdrawal or post-acute withdrawal symptoms. Laboratory assessment was negative or unremarkable. Evaluation on admission for residential level services revealed a mental status examination that was free of severe psychiatric symptoms. Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was discharged against medical advice despite plans to immediately begin residential level treatment. 

The requested health service/treatment of Inpatient Chemical Dependency Rehabilitation Admission is not medically necessary for this patient. The inpatient treatment and other inpatient medical services  could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and other substances of abuse. The patient had been evaluated and cleared with regard to safety concerns and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns. This answer is consistent with established practice guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) Criteria, as referenced below, and is entirely consistent with NY State instruction for this review including the application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.