Appeal type: Medical necessity
Decision: Overturned

The patient is male who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol and opioid use disorders. The patient was using an anxiolytic (Xanax) on an intermittent and frequent basis with up to 4 milligrams (mg) once to twice per week. He was using large amounts of alcohol with up to one pint of liquor per day, and up to 40 bags of heroin. The patient had experienced severe alcohol/anxiolytic and opioid withdrawal in the past and had moderately severe withdrawal at the time of admission with sweats, chills, tremors, body aches, head ache, and rhinorrhea, as well as anxiety, irritability and restlessness with Clinical Institute Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Scale (COWS) scale scores of 12 and 10, respectively. He had experienced severe withdrawal symptoms in the past requiring detoxification including detoxification treatment in the past year with relapse.
    
The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a Librium and methadone together with vitamin replacement therapy, and medical monitoring. Following his third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. His mental status examination included persistent symptoms of depression with associated symptoms of anxiety, agitation, irritability and insomnia. He had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He was treated with paroxetine and trazodone and prn medications to address pain, anxiety, agitation insomnia. Vitamins were continued, as well as the comfort medications and monitoring, and assistance with daily activities.
The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. He did continue with detoxification treatment was maintained on fall and seizure precautions. Again, he was provided education and counseling during the remaining hospital stay. The patient was discharged with recommendations for clinically appropriate aftercare, as well as recommendations for involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). He was discharged with referral for rehabilitation substance use disorder treatment.

The health plan's determination is overturned.

The inpatient services for detoxification treatment, withdrawal management and stabilization and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care, as noted in the answer to question 1. The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the comorbid psychiatric disorder that was triggering his continued use of substances. Withdrawal symptoms were managed with tapering dosages of benzodiazepine and methadone requiring monitoring and prn medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.