Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Continued residential treatment

Determination:
The Continued residential treatment was not medically necessary.

The patient is an adult male. He was referred for residential rehabilitation substance use disorder treatment to address longstanding and severe alcohol use disorder. The patient has no history of withdrawal seizures or delirium tremens. He was self-referred due to difficulty with the social environment and coping problems related to the substance use disorder. His history of substance use included complications including a stroke three years prior to admission and memory problems that were presumed to be due to Wernicke-Korsakoff syndrome.

The patient has no history of psychiatric disorder or treatment and no acute general medical issues.

The patient is single, homeless and unemployed and was living with his mother. He had no current legal issues.

Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, and fair judgment. The patient was described as cooperative with fluent speech and organized thought processing. He displayed anxious mood, and diminished focus or concentration and memory with no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal ideation or aggressive impulses. There were no significant withdrawal symptoms or post-acute withdrawal symptoms.

On admission, the patient received comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with groups, as well as other therapeutic activities. Psychiatric evaluation was provided and affirmed that the patient had no co-occurring psychiatric disorders. The patient readily engaged in substance use disorder rehabilitation treatment. 

By the date of service under review, the patient was noted to be engaged in the therapeutic activities, social with peers and participating in recovery/educational groups, and adherent with medication that included vitamin supplements. Throughout his stay, the patient remained stable with regard to mental status and engaged with respect to the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the residential treatment program including 24-hour monitoring. 

The patient was discharged from stabilization to intensive residential level care with plans for clinically appropriate treatment of his substance use disorders. He was prescribed no medications other than vitamins and was advised to follow up with a primary care physician and consider smoking cessation.

The patient presented with substance use disorder with alcohol. He self-referred and received residential level "stabilization" treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues. During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the continued residential level of care, structure or 24-hour monitoring. The application of NY State OASAS LOCADTR 3.0 Criteria did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the continued residential substance use disorder treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines.