Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance abuse inpatient.
 The insurer denied the inpatient rehabilitation. The denial is upheld in whole.

The patient is a male who was transitioned from detoxification treatment to inpatient substance use disorder rehabilitation treatment to continue to address substance use of stimulants (crack cocaine); cannabis (marijuana); tobacco, and alcohol. The patient had no past history of withdrawal seizures, delirium tremens or severe withdrawal symptoms. He had a history of substance use disorder with onset in adolescence with alcohol, escalating to daily continuous use with subsequent use of crack cocaine at age 25 years. He was using one to two pints of liquor plus beer together with $100 worth of crack cocaine with daily use. He was also using marijuana intermittently. His substance use had resulted in psychosocial problems including homelessness and unemployment. He self-referred to substance use disorder treatment with medical clearance and detoxification treatment prior to beginning inpatient rehabilitation treatment.

The patient exhibited limited insight and impaired judgment with questionable control of impulses. There were no severe symptoms on mental status examination; the patient had no symptoms of severe depression, mania, psychosis, perception, cognition, or thought disorder. He reported sleep disturbance, but no other somatic symptoms.

The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the inpatient treatment program. The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment. He received vitamin and nicotine replacement therapy and comfort medications including trazodone and Vistaril to address anxiety and insomnia. The patient participated in therapy. He was actively participating in treatment with treatment plans to address coping skills and to develop sober supports. He had no complications during his brief inpatient stay and transferred to a sister rehabilitation program with plans for continued substance use disorder treatment. The subject under review is the medical necessity for the inpatient rehabilitation. 

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient rehabilitation is not medically necessary for this patient. The inpatient rehabilitation was amenable to treatment at a lower level of care. The patient was motivated and able to effectively engage in rehabilitation services, and the patient did not need the continued structure or monitoring of an inpatient setting or the intensity of therapy and services in order to effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required continued residential level behavioral health and substance-related services. Moreover, the patient was motivated to participate in rehabilitation treatment. Thus, the requested benefit of inpatient rehabilitation was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as 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.