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 with diagnoses of cannabis dependence, cocaine dependence, and alcohol dependence in early full remission. He was admitted to the inpatient rehabilitation level of care. History and physical reports that the patient was seeking admission for rehab for cocaine use. He had been using $100 worth on a daily basis and had last used the day before admission. He also admitted to daily marijuana use. He reported a history of drinking 1 pint of alcohol less than 3 times per week. He denied any withdrawal symptoms from alcohol.

The patient's urine drug screen was positive for cocaine and THC (tetrahydrocannabinol). Behavioral health progress note indicates that the patient stated that he was going to rehab. He declined to state if he had recently detoxed. His vital signs were stable. Counseling note indicates that the patient had no health concerns, was unemployed, and received SSI (supplemental security income) benefits. He reported a diagnosis of bipolar disorder but reported that he was not currently taking any medications. He denied any legal issues.

Behavioral Health consult note the day after admission reports that the patient declined to speak with the physician. It notes that the patient is known for having multiple admissions to the facility. There were no acute medical problems noted. Discharge summary indicates that the patient was discharged against medical advice. Outpatient follow up was arranged.

Coverage was denied by the health plan stating that medical necessity for inpatient substance abuse rehabilitation was not met using LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) guidelines, because the patient was able to participate in treatment outside of a 24-hour structured setting, did not have social, emotional, or developmental barriers to participation in treatment outside the inpatient level of care, did not have a co-occurring medical or psychiatric condition requiring inpatient care, was not at risk for complications from withdrawal, was not suicidal, homicidal, or psychotic, had some motivation to be in treatment, and did not require the 24-hour monitoring of the inpatient rehabilitation level of care. The denial decision was appealed by the treating facility who state that the admission was medically necessary because the patient's long-standing history of substance abuse, his disability, and his current social situation put him at high risk for relapse. The health plan upheld the denial decision using the same rationale as previously.

The Inpatient Rehabilitation Admission was not medically necessary.

Per LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria, the patient does not meet criteria for inpatient rehabilitation services. There is no documentation of lack of a safe environment that can support outpatient treatment. There is no documentation of serious medical symptoms that need to be managed in an inpatient rehab setting in order for substance use disorder treatment to be effective. There is no document in of use in hazardous situations or frequencies likely to imminently cause severe physical or emotional harm to self or others. There is no documentation of interpersonal or personal skills deficits requiring the support of a residential setting. There is no documentation of strong cravings or urges to use that are unmanageable or behavioral or emotional instability. There is no documentation of lack of stable access to food and shelter. As such, the patient does not meet criteria for inpatient rehabilitation level of care per LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria. Since medical necessity typically includes that a treatment or service must be appropriate in terms of setting, inpatient rehab level of care is not medically necessary for the patient.