Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient Rehabilitation Services
The insurer denied the Inpatient Rehabilitation Services.
The denial is upheld. 

The patient is a male who completed detoxification treatment and was converted to inpatient rehabilitation and substance use disorder treatment to address a seven-year history of severe substance use disorders with alcohol and opioid (heroin and buprenorphine) class substances. The patient has no history of withdrawal seizures or delirium tremens. He had extensive treatment experience with at least six detoxification episodes and two rehabilitation treatment episodes that included one outpatient and one residential level treatment. His substance use included one pint of vodka daily, and 20 to 30 bags of heroin with inhalation, and intermittent use of buprenorphine when unable to obtain heroin.

The patient has no history of psychiatric disorder and denied history of psychiatric hospitalization or suicidal behavior.

The patient has no acute general medical issues; he was medically screened upon admission with laboratory assessment and physical examination that were grossly normal or unremarkable. He had a history of chronic obstructive pulmonary disease (COPD) with emphysema with at least one hospitalization related to his lung disease. He was tobacco dependent.

The patient is divorced and retired with a pension and lives with family who were supportive. There was no history of legal issues or trauma history in this case.

Evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. The patient was described as cooperative with fluent speech and organized thought processing. He displayed euthymic mood, and, diminished focus or concentration 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 or severe withdrawal symptoms or post-acute withdrawal symptoms upon completion of his detoxification.

Upon admission to inpatient level services, 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 12-step recovery groups and other therapeutic activities. Psychiatric evaluation had been provided and affirmed that the patient had no co-occurring psychiatric disorders. The patient engaged in substance use disorder rehabilitation treatment. He was noted to participate in the therapeutic activities, was social with peers and was actively participating in recovery groups, and, adherent with medication that included vitamin supplements and the availability of nicotine replacement to address tobacco dependence, as well as 'as needed' (PRN) use of Vistaril and trazodone for anxiety and insomnia. He was sleeping and eating okay with steady gait and functioning with daily activities.

Throughout his brief inpatient stay, the patient remained stable and engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged against medical advice with recommendations for clinically appropriate aftercare of his substance use disorders and a reminder that he had left treatment prematurely two previous times and would not be converted to inpatient rehabilitation services with future detoxification treatments. 

No, the requested inpatient stay is not medically necessary for this patient.

The patient presented following detoxification treatment with substance use disorders, diagnosed with alcohol and opioid and tobacco use disorders. He briefly received inpatient level rehabilitation treatment and left treatment against medical advice. He did engage in treatment and he had no biomedical or psychiatric treatment issues that warranted inpatient level care. 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 brief inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring. The application of 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) 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 inpatient level treatment for substance use disorder rehabilitation treatment is not met in this case scenario, consistent with the American Society of Addicition Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of stability that included no significant withdrawal symptoms or biomedical issues and no co-occurring psychiatric disorders 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 rehabilitation treatment. 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 State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria, referenced below.