Diagnosis: Substance abuse
Issue under review: Inpatient rehabilitation

Determination:
The Inpatient rehabilitation was not medically necessary.

The patient presented with substance use disorders with use of opioid and cannabis class substances of abuse. Upon referral for substance use disorder treatment, the patient readily engaged in treatment with reasonable motivation due to his desire to return to employment and find housing. During the time interval under review, the patient was noted to be in no apparent distress with satisfactory daily functioning and active participation in treatment including positive interactions with staff and peers. There were no emerging treatment issues or biomedical or co-occurring psychiatric issues that would have warranted 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 asserts. Thus, medical necessity for the Inpatient rehabilitation admission is not met in this case scenario. This answer is consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below, as well as the application of NY State OASAS LOCADTR 3.0 Guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for the admission or continued inpatient level of care during the time interval under review. The patient's clinical features did not include residual withdrawal symptoms, biomedical complications or co-occurring psychiatric symptoms or disorders that would have warranted inpatient level care. His treatment did not require 24-hour monitoring or the structure or intensity of inpatient level services. There were no safety concerns in this case. He readily engaged with treatment with reasonable motivation, and was involved with peer supported recovery groups while participating in educational sessions and other evidence-based treatment to address the substance use disorders. The patient could have been safely and effectively treated at a lower level of care in a less restrictive setting with sober supports and clinically appropriate monitoring to assure abstinence. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the substance use disorders diagnosed and under treatment in this case, as well as the NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.