Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission for substance use disorder rehabilitation treatment
The insurer denied the Inpatient admission for substance use disorder rehabilitation treatment.
The denial is upheld. 

The patient is a male self-referred for inpatient rehabilitation and substance use disorder treatment to address longstanding substance use disorders with alcohol and stimulant (cocaine and other stimulant substances) and opioid class substances with onset of alcohol use disorder in adolescence and progression to the use of cocaine and heroin. The patient has no history of withdrawal seizures or delirium tremens. He was referred due to difficulty with the social environment and coping problems related to the substance use disorders, and with the encouragement of family and friends. He had limited treatment experience with a rehabilitation treatment episode with one year of sobriety and relapse. His substance use included one-half to one pint of cognac, one-half gram of heroin with inhalation, and $100 worth of cocaine on a daily continuous basis.

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, chest x-ray and physical examination that were grossly normal or unremarkable. He had a remote history of treatment for a gunshot wound and a stab to the lungs. He had childhood asthma and used a rescue inhaler. He was also tobacco dependent at one-half pack per day for several years.

Throughout his inpatient stay, the patient remained stable with no withdrawal symptoms 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. 

No, the requested Inpatient admission for substance use disorder rehabilitation treatment is not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and opioid and tobacco use disorders. He self-referred and briefly received inpatient level rehabilitation treatment. He readily engaged in treatment and 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 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 OASAS 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 admission for substance use disorder rehabilitation treatment is not met in this case scenario, consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.