Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Issue under review: Inpatient substance abuse treatment 
The insurer denied the Inpatient substance abuse treatment. 
The denial is overturned. 

Yes, the proposed treatment, inpatient substance abuse treatment, was medically necessary for this patient.

The patient is a male who presented to the emergency department requesting detoxification treatment and was admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin) and stimulant (cocaine) class substances, as well as use of cannabis and sedative-hypnotic-anxiolytic class drugs of abuse. The patient had been using up to 15 bags of heroin with intravenous (IV) administration and intermittent use of up to $20 of cocaine as well as up to three bars of Xanax and an unspecified amount of cannabis. He had a history of prior detoxification and substance use disorder treatments with his most recent detoxification treatment episode one month prior to his admission with relapse. His self-referral for treatment was prompted by multiple stressors including occupational, primary support, housing, social environment and other psychosocial domains, and, he had somatic complaints that included headache, nausea and back pain with withdrawal symptoms and a Clinical Opiate Withdrawal Scale (COWS) score of 15 reflecting moderate withdrawal symptoms from heroin.

The patient has no history of a psychiatric disorder and denied past history of suicidal or self-harming behaviors.

The patient presented without acute co-morbid general medical issues. He was hepatitis C positive and untreated. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history. The patient is an every day smoker and tobacco dependent at one pack per day.

The patient is single, homeless and unemployed with limited family support and a strained relationship with his family. There were no legal issues in this case.

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with a full range of affect with nervousness, tension, irritability, sleep disturbance, and aches due to the onset of opioid withdrawal. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses. His onset of withdrawal symptoms had initially included anxiety, irritability, insomnia, agitation, nausea and diarrhea, sweats, chills and body aches. His COWS scale score diminished as treatment was started and in response to treatment in the emergency department.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone, and as needed (PRN) medications for comfort, as well as vitamin replacement therapy. He had the availability of nicotine replacement and smoking cessation education. The program provided for case management with referral to sober housing and access to rehabilitation treatment that included comprehensive evidence-based treatments. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and, involvement with counseling and milieu activities including peer support and education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal during his brief stay. 

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of methadone. Withdrawal symptoms remained mild and resolved after the first two days of treatment. The patient completed the detoxification treatment and declined referral for rehabilitation treatment. He was discharged. 

The requested inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin, together with cocaine, Xanax and cannabis that did warrant the admission for inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient had a positive drug screen that included opioid as well as other substances of abuse consistent with history. He had moderate and persistent withdrawal symptoms through day two, and, the patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn medications. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and with New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.