Diagnosis: Substance abuse
Treatment: Inpatient stay

The insurer denied the inpatient stay.
The health plan's determination is upheld.

The case involves a female who presented for inpatient treatment to address substance use disorder with a stimulant (crack cocaine) class substance. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She had a history of substance use disorder with escalating use of crack cocaine with up to $150 worth on a daily basis; she had no prior substance use disorder treatment. She was referred for treatment by her counselor with the goal of stopping the cycle of use which was triggered by comorbid psychiatric conditions (anxiety and depression), as well as physical and mental abuse by her boyfriend.

Inpatient Admission is not medically necessary for this patient.
The patient presented with substance use disorder with use of crack cocaine, referred for treatment by her mental health counselor. She readily engaged in treatment with reasonable motivation. During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. There were no biomedical, emotional/psychiatric or other clinical features that would have required inpatient level monitoring or structure. The application of New York 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. Thus, medical necessity for the admission is not met in this case scenario and is consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines.