Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Rehabilitation Admission
The insurer denied Inpatient Rehabilitation Admission.
The denial is upheld.

The patient is an adult male. He was referred from a general medical facility for inpatient rehabilitation and substance use disorder treatment. The patient has a history of longstanding substance use disorders with alcohol and stimulant (cocaine) class substances with no prior treatments. The patient has no history of withdrawal seizures or delirium tremens. He was referred after presenting with chest pain in association with the 
substance use disorders due to difficulty with the social environment and coping problems mostly related to the substance use disorders in the context of family problems. His history of substance use included use of large quantities of alcohol and up to one gram of cocaine on a daily continuous basis. He identified psychosocial stressors and consequences as a major concern including problems with housing, occupational, primary support, and social environment domains. The patient has a history of psychiatric disorder with a diagnosis of an unspecified anxiety disorder and major depressive disorder, as well as trauma history with childhood sexual abuse and verbal abuse from his sister; he denied history of psychiatric hospitalization or suicidal behavior. The patient had been medically screened with detoxification prior to admission for rehabilitation treatment including laboratory assessment and physical examination which were grossly normal or unremarkable. The patient is employed and was living with his father and with limited family support. He denied legal issues, but has trauma history as noted, as well as ongoing abuse from his sister. There were no significant withdrawal symptoms or post-acute withdrawal symptoms though he displayed anxiety and motor agitation. He also reported insomnia. The patient was discharged on day # (number) 22 with plans for clinically appropriate aftercare. The denial was based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that there were no acute symptoms or serious withdrawal symptoms or general medical or psychiatric issues that would have required inpatient level services. The denial determination indicated that the patient was capable of participating in treatment with lower-level services. The treatment facility appealed based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that inpatient level treatment was the appropriate level of care. The appeal was based on the clinical features of the case with the negative influence of the social environment with severe psychosocial stressors and co-occurring psychiatric disorders.

The requested inpatient substance-related rehabilitation treatment was not medically necessary.

This patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use disorders. He received inpatient level rehabilitation treatment. During the time interval under review, the patient was noted to be in no apparent distress other than anxiety with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout the patient's inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care or structure or 24-hour nursing monitoring, as the health plan asserts. The application of New York 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. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the dates of service under review is not met, consistent with the American 
Society of Addiction Medicine (ASAM) criteria, the scientific literature and published guidelines, referenced below, and with the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 criteria.