Diagnosis: Substance abuse
Treatment: Substance abuse residential
The insurer denied Inpatient Chemical Dependency Rehabilitation Services. The health plan's determination is upheld.

The patient is an adult male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine), alcohol, hallucinogen (hallucinogens (phencyclidine) (PCP)) and cannabis (marijuana) use disorders. The patient was using $(dollar)50 worth of cocaine, one bag of marijuana, and use of one and one-half pints of alcohol daily, as well as use of PCP. The patient was also tobacco dependent with light use.

Inpatient Chemical Dependency Rehabilitation Services were 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. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with clinically appropriate structure, monitoring and sober supports. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment.
Again, 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 through Discharge. Thus, the requested inpatient substance use disorder rehabilitation services was not medically necessary for this patient.