Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction/substance withdrawal
Treatment: Substance Abuse/Inpatient/Inpatient chemical dependency rehabilitation
The health plan denied the requested inpatient chemical dependency rehabilitation stay as not medically necessary. 
The health plan's determination is upheld.

Clinical summary: The patient is an adult male who was admitted for inpatient rehabilitation substance use disorder treatment in order to address substance use disorder with opioid and stimulant (cocaine) class substances of abuse. 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 participation in a Methadone maintenance treatment program for ten years at a dose of 150 mg (milligrams) per day at the time of admission. He had relapsed 5 months prior to his admission precipitated by the anticipated loss of his room rental with daily use of up to 5 bags of heroin together with the Methadone, and use of $ (dollars) 50 worth of cocaine two times per week. He was also prescribed Xanax 2mg three times per day.

Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the treatment program. The patient was social with peers and participating actively in treatment with continued risk for relapse; the patient had no severe withdrawal symptoms or post-acute withdrawal symptoms or craving, and he had no complications with respect to biomedical, general medical, emotional, or other treatment domains. Progress notes reflected stable mood with sleep and appetite that were okay. The patient completed inpatient treatment and was discharged to a structured shelter with plans to immediately return to outpatient level treatment with the methadone program and with recommendation for continued involvement in recovery groups.

The health plan's determination of medical necessity is upheld.

No, the requested health service/treatment of Inpatient chemical dependency rehabilitation was not medically necessary for this patient.
The patient in this case scenario is not clinically appropriate for the inpatient rehabilitation level of care during the time interval under review. The patient did not need the intensity or duration or 24-hour nursing staff monitoring of an inpatient level of care. The patient was motivated and able to engage with treatment and be involved with peer supported recovery groups while continuing medication assisted treatment with methadone. The patient could have been effectively managed with lower-level services consistent with New York State OASAS LOCADTR 3 Guidelines. Thus, the health plan's determination is reasonable in this case scenario.
The patient presented with substance use disorders with use of opioid and cocaine class substances while participating in a methadone maintenance treatment program. He was admitted to inpatient level rehabilitation treatment. He readily engaged in treatment with continued use of methadone and comfort medications and medications to treat the associated symptoms of anxiety, depression and insomnia. During the time interval under review, the patient was noted to be in no apparent distress with active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted the admission or the inpatient level of care. The application of NY State OASAS LOCADTR 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 asserted in the denial.