Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Residential Rehabilitation Services. 

The insurer denied the Residential Rehabilitation Services. 
The denial is upheld. 

The patient is a adult male. He self-referred for long-term substance use disorder rehabilitation treatment to address longstanding substance use disorders with alcohol and stimulant (cocaine) and opioid (heroin) class substances with onset in adolescence and progression to the use of up to 30 bags of heroin daily with intranasal administration together with up to one pint of cognac and $20-40 worth of crack cocaine. 

Prior to his admission, the patient had received detoxification treatment and rehabilitation treatment. Prior to that treatment episode, the patient had only brief treatment with relapse. The patient has no history of withdrawal seizures or delirium tremens. He was referred for long-term treatment due to difficulty with the social environment and coping problems related to the substance use disorders, and with the encouragement of family and friends. Again, he had limited treatment experience with a rehabilitation treatment episode with immediate relapse. 

Upon admission to residential 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 groups, as well as 12-step recovery groups and other therapeutic activities. Psychiatric evaluation had been provided and affirmed that the patient had no severe co-occurring psychiatric disorders, but he did have the trauma history and symptoms of depression and anxiety and insomnia. The patient declined any psychotropic medications other than use of clonidine and trazodone. 

Throughout his residential stay, the patient remained stable with no post-acute withdrawal symptoms and was engaged with the treatment regimen, as noted and as clinically appropriate. He received intensive rehabilitation services, monitoring, and structure provided within the residential treatment program including 24-hour monitoring and monitoring for abstinence with use of therapeutic leaves. 

Note: Submitted records indicate subsequent treatment for lapses and the patient's struggle to remain abstinent from substances of abuse in part due to the influence of peers and poor impulse control and coping skill deficits. 

No, the requested substance use disorder rehabilitation treatment for the dates of service under review is not medically necessary for this patient. 

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and opioid/heroin and tobacco use disorders. He self-referred and had residential level rehabilitation treatment prior to admission for long-term residential treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted continued residential 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 with attendance at recovery groups. Throughout his residential stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the request for continued residential level of care, structure or 24-hour monitoring. 

The application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 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 continued substance use disorder rehabilitation residential treatment is not met in this case scenario, consistent with ASAM (American Society of Addition Medicine) Criteria, the scientific literature and published guidelines, referenced below.