Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polysubstance Use
Treatment: Inpatient Substance Rehabilitative Treatment With 24 Hours a Day Nursing Support
The insurer denied the Inpatient Substance Rehabilitative Treatment With 24 Hours a Day Nursing Support
The denial is upheld

The patient is a female. She was referred for inpatient rehabilitation and substance use disorder treatment in order to address opioid (heroin) and stimulant (cocaine) class substance use disorders. The patient had been using opioid and cocaine substances of abuse while receiving methadone in a methadone maintenance treatment program (MMTP). Her referral was prompted by her failure to remain abstinent. She incurred legal charges that included possession of controlled substances and burglary, and she had been incarcerated and released with mandatory treatment ordered. Her referral had been coordinated by an agency providing oversight for the patient.

The patient's evaluation on admission revealed a mental status examination that reflected external motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses with questionable motivation. The patient was described as superficially cooperative with fluent speech and organized thought processing. She displayed okay mood with no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment (dementia or delirium). She did not report suicidal ideation or aggressive impulses. She was dysphoric and irritable with reports of mood swings and sleep disturbance.

Upon entering treatment with 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 therapy groups, as well as recovery groups and other therapeutic activities to support her efforts at rehabilitation treatment. The patient did not readily engage in substance use disorder rehabilitation treatment, but indicated that she was planning to cut treatment short in order to proceed to long-term treatment.

Throughout her brief inpatient stay, the patient remained unstable with regard to mental status and remained uncooperative with respect to the treatment regimen which had included focus on coping skills and plan for the development of a relapse prevention plan while providing motivational enhancement. She received methadone at 20 mg (milligrams) daily and vitamin supplements, and she was restarted on lithium and Abilify with prn (as needed) use of trazodone, as well as comfort medications.

The patient continued treatment with intensive services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged against medical advice with refusal of a Narcan kit and declining recommendations for clinically appropriate aftercare. The patient was adamant that she would proceed to the long-term facility on her own.

The health plan's denial determination was 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) Criteria and medical necessity indicating that the patient could have been treated with lower-level services suggesting residential level care. The denial determination referenced that the patient had no physiologic or general medical disturbance or other comorbidities that would have required an inpatient level of care.

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) Criteria, as well as the need to complete treatment with development of better coping skills and identification of triggers to prevent relapse.

No, the requested  Inpatient Substance Rehabilitative Treatment With 24 Hours a Day Nursing Support was not medically necessary.
The patient presented with substance use disorders with use of opioid and stimulant class substances while participating in an outpatient substance use disorder treatment with medication assisted treatment with methadone which had been started while the patient was in a correctional facility. She was referred for mandatory treatment of the substance use disorders as an alternative to incarceration. Upon referral for substance use disorder treatment, the patient engaged superficially in treatment, but left against medical advice due to her desire to continue treatment in a long-term treatment program.

During the time interval under review, the patient was noted to be in no apparent distress with satisfactory daily functioning and participation in treatment including positive interactions and peers, but conflict with staff over the need to complete the 28-day rehabilitation program. Nonetheless, during the brief inpatient stay, there were no emerging treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the inpatient level of care. 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) 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 asserted. Thus, medical necessity is not met in this case scenario. This answer is consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below.

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 the admission or continued inpatient level of care during the time interval under review. The patient's clinical features did not include residual withdrawal symptoms, biomedical complications or co-occurring psychiatric symptoms or disorders that would have warranted inpatient level care and monitoring. The patient's treatment did not warrant the structure or intensity of inpatient level services. The patient could have been safely and effectively treated with lower-level care in a less restrictive setting with sober supports and clinically appropriate monitoring to assure abstinence. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice, as well as the 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/Guidelines, referenced below.