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202002-125381

2020

HIP Health Plan of New York

HMO

Substance Abuse/ Addiction

Substance Abuse: Inpatient

Medical necessity

Upheld

Case Summary

Substance abuse/Addiction
Substance Abuse: Inpatient

Diagnosis: Substance abuse. Treatment: Inpatient rehab. The insurer denied inpatient rehab. The health plan's determination is upheld.

The patient is a male who presented for inpatient rehabilitation substance use disorder treatment to address substance use disorder for alcohol abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a ten-year history of alcohol use. He reported intermittent use of alcohol with up to one pint of tequila up to three times per month.

Inpatient Substance Use Rehabilitation Treatment is not medically necessary for this patient.
The patient presented with alcohol use disorder with the request for treatment. He was admitted and received inpatient level rehabilitation treatment. He readily engaged in treatment with evidence-based psychosocial treatments. During the brief time interval under review, the patient was noted to be in no apparent distress with satisfactory functioning and active participation in treatment including positive interactions with staff and peers. Throughout his brief stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting.

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