Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stimulant and sedative-hypnotic anxiolytic class
substance use disorders
Treatment: Continued Stay Residential Rehabilitation
The insurer denied the Continued Stay Residential Rehabilitation.
The denial is upheld.

The patient is a adult male. He was referred by the drug court and court mandated
for residential substance use disorder rehabilitation services in order to address
severe stimulant (methamphetamine) and sedative-hypnotic anxiolytic
(benzodiazepine) class substance use disorders. His substance use had escalated
to continuous daily use in the years prior to presentation in the context of severe
stressors including legal issues and a decline in functioning. The patient had
previously received formal substance use disorder treatment without sustained
sobriety or abstinence. He continued use of 0.25 grams of methamphetamine
(crystal meth) daily with smoking and one-third bar of Xanax. He did not have a
history of seizures or delirium tremens or other severe withdrawal issues in the
past.

The patient was admitted to residential level rehabilitation services. The patient
engaged superficially in substance use disorder treatment including group and
milieu interventions, as well as educational sessions. He had the opportunity to
participate in recovery groups with peer support. Continued rehabilitation treatment was being planned to include continued focus on coping skills, relapse prevention with identification of triggers, education about the disease model of addiction, and
active involvement with recovery groups, as well as other interventions to support a recovery effort. The patient had no complications with treatment and no safety
concerns during the time frame. He was noted to have control of impulses and had
not shown severe psychiatric symptoms. He was taking psychotropic medications
including Lexapro, Topamax and trazodone, as well as melatonin. He had
medication adherence and tolerability with ongoing medication management with
the psychiatric consultant.

No, the Continued Stay Residential Rehabilitation: Ongoing treatment is not
medically necessary for this patient in keeping with NY (New York) State OASAS
(Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and
drug treatment referral) 3.0 Guidelines/Criteria.

The residential substance abuse rehabilitation treatment in this case scenario was
amenable to treatment at a lower level of care. The patient was externally motivated
and able to effectively and superficially engage in rehabilitation services, and the
patient did not need the structure or 24-hour monitoring of an inpatient setting in
order to safely and effectively participate in rehabilitation substance abuse
treatment. There were no biomedical or psychiatric complications, or severe
psychiatric symptoms/disorders in this case that would have warranted the
continued inpatient level services and treatment. Moreover, the patient
demonstrated his motivation and intent to follow the mandate for continued
involvement in the substance use disorder treatment, as noted in the clinical
summary. Thus, the requested benefit of residential substance use disorder
treatment for the dates of service under review was not/is not medically necessary
for this patient.

This answer is consistent with prevailing standards of professional practice, ASAM
(American Society of Addiction Medicine) Criteria, and the scientific literature,
referenced below, as well as New York State instruction for medical necessity
reviews together with the NY (New York) State OASAS (Office of Addiction
Services and Supports) LOCADTR (level of care for alcohol and drug treatment
referral) 3.0 Criteria, applicable in this case.

The structure and intensity of services necessary for continued
rehabilitation/substance use disorder treatment can be/could have been effectively
provided at a lower level of care in a less restrictive treatment setting with sober
supports. There is no evidence that residential level structure and monitoring is
medically necessary for a successful outcome. There were no biomedical,
psychiatric or general medical issues that warranted the continued residential level
treatment in this case scenario.

Thus, as the health plan asserts, the patient's substance use disorders were
amenable to treatment at a lower level of care in this case scenario, and the health
plan's determination of medical necessity was consistent with 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/Guidelines,
referenced below, as well as ASAM (American Society of Addiction Medicine)
Patient Placement Criteria and the scientific literature and published guidelines,
also referenced below.