Diagnosis: Substance abuse
Treatment: Inpatient admission

The proposed treatment, inpatient admission for detoxification and withdrawal management and other medical services, was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of unspecified anxiety and depressive disorder and ongoing substance use disorders with alcohol, opioid and stimulant class substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (ASAM) Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted above. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. The Inpatient admission or detoxification and withdrawal management and other medical services were therefore not medically necessary in this case scenario, as the health plan asserts, and the health plan's determination of medical necessity and decision is reasonable and clinically appropriate. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the proposed inpatient level of care, as referenced below.