The patient who completed detoxification treatment and had received inpatient rehabilitation substance use disorder treatment with admission/transfer for continued inpatient level services for rehabilitation substance use disorder treatment of opioid (heroin) use disorder.The health plans determination of medical necessity is upheld in whole. The structure and intensity of services necessary for a successful 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 inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome in this case. And, there were no biomedical, psychiatric or general medical issues that warranted the admission/transfer for inpatient level treatment.
Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment, Thus, the requested benefit of Inpatient substance abuse rehabilitation services was not medically necessary for this patient. This is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature.