Diagnosis: Substance Abuse.
Treatment: Inpatient Admission.

The insurer denied the Inpatient Admission.
The determination is upheld.

The patient is an adult male who was self-referred and was admitted to inpatient rehabilitation substance use disorder treatment for stimulant (crack cocaine) use disorders. The patient was using up to $50 worth of crack cocaine daily. The patient was also tobacco dependent at one pack per day with 22 pack years. His referral was prompted by his desire to stop using substances of abuse after longstanding use and a decline in functioning with homelessness and unemployment. He had a history of multiple past substance use disorder treatment episodes with multiple past detoxification treatments and rehabilitation treatment.
The mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. His mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. He had no evidence for cognitive impairment, perceptual disturbance, mood disturbance or psychosis. Insight was limited with impaired judgment due to the addiction. He had sleep disturbance with insomnia.
The patient easily transitioned to rehabilitation treatment. He actively participated in individual, group, and educational sessions. He was prescribed vitamins and comfort medications with the availability of nicotine replacement therapy. He received consultations for general medical conditions and psychiatric evaluation without complication.
Discharge planning occurred that included recommendation for continued residential aftercare upon completion of the program. The patient was cooperative and engaged throughout his inpatient stay.

At issue is the medical necessity of an inpatient admission.

The requested health service/treatment of inpatient admission was not medically necessary for this patient. The inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care, as noted above. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for his cocaine use disorder.

There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment. Thus, the requested benefit of inpatient substance use disorder rehabilitation services was not medically necessary for this patient. This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and the scientific literature, referenced below together with the application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.