Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Inpatient. 
The insurer denied: Inpatient Chemical Dependency Rehabilitation Admission. 

The health plan's determination is upheld in whole.

The patient is a male who presented for inpatient rehabilitation substance use disorder treatment to address substance use disorder with stimulants (cocaine); alcohol; and opioids (heroin). The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior treatments with relapses and no substantial periods of sobriety in the past. He was using cocaine at approximately 7 bags per day with intravenous (IV) administration; and frequent use of alcohol with up to one pints of vodka per day; and opioids with up to 15 bags of heroin with daily use and IV administration. He denied recent use of alcohol and had a blood alcohol level of zero consistent with history; his urine drug screen was positive for cocaine, opiates and methadone. Again, the patient had previously engaged in substance use disorder treatment, as well as detoxification prior to his admission.

Throughout the brief inpatient stay, the patient was provided treatment with intensive services, sober housing, monitoring, and structure provided within the inpatient substance use disorder treatment program. The patient had no severe withdrawal symptoms or post-acute withdrawal symptoms. The patient had no complications with respect to biomedical, general medical, emotional or other treatment domains. Mental status examinations/progress notes reflected stable mood with sleep, appetite and energy that were okay. However, he asked to leave the program due to general medical concerns and he was discharged against medical advice with referral for clinically appropriate aftercare and continuation of his prescribed medications for hepatitis C.

The health plan's determination is upheld in whole.

The requested health service/treatment of Inpatient Chemical Dependency Rehabilitation Admission is not medically necessary for this patient.

The patient in this case is not clinically appropriate for inpatient level of care. The patient did not need 24-hour monitoring or the structure of inpatient treatment to address the substance use disorders with rehabilitation treatment. There were no complications or severe symptoms that warranted inpatient level treatment, as proposed. The patient could have been effectively treated with lower level care in a less restrictive treatment setting.

The patient presented with substance use disorders with use of heroin, alcohol and cocaine with daily or near-daily use. The patient was noted to be capable of active participation in treatment and had no significant withdrawal symptoms or acute medical concerns or safety concerns. He had no co-occurring psychiatric disturbance or disorder. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting. Thus, medical necessity for the admission is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.