Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol and opioid class substances of abuse, as well as use of prescribed and non-prescribed benzodiazepines. He had recent substance use disorder treatment in the previous year, but had left treatment prematurely and relapsed and was using large quantities of alcohol and opioids on a continuous daily basis. He had multiple prior substance use disorder treatments with a chronic relapsing course, and history of two prior overdoses with one requiring the use of Narcan. His substance use disorder history was associated with escalating use and progression of the disease.
At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. He was unemployed and reported severe psychosocial stressors within the primary support, social environment, occupational and housing domains with homelessness. The patient reported functional decline as the substance abuse/disease had progressed together with homelessness which prompted his self-referral for detoxication treatment and request for assistance with rehabilitation services.
The patient provided no past history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. He was medically screened and admitted for inpatient level detoxification with plans for a five day detoxification treatment with Librium and methadone and supportive measures. His Clinical Institute Withdrawal Assessment (CIWA) / Clinical Institute Narcotic Assessment (CINA) scale scores showed mild withdrawal symptoms with a score of 8. Withdrawal symptoms and signs included sweats, tremor, diaphoresis, restlessness, and anxiety, as well as insomnia. A drug screen was consistent with history.
The patient has no history of psychiatric disorders or treatment or suicidal or self-harming behaviors. There were no acute medical issues in this case other than the alcohol and opioid withdrawal, and the healing abdominal wound requiring continued antibiotic treatment. The patient was tobacco dependent and declined nicotine replacement therapy.
On Mental Status Examination, there were no severe symptoms on mental status examination and no safety concerns with regard to risk of harm to self or others. The patient displayed fair to good insight despite his history, and impaired, but good judgment and control of impulses. He demonstrated symptoms of anxiety with generalized symptoms including insomnia, and dysphoric affect together with somatic symptoms related to the alcohol and opioid withdrawal, as noted.
The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and methadone and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, agitation, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal during the hospital stay, and the patient reported persistently mild symptoms of withdrawal that diminished and responded to use of prn medications administered through discharge. He was participating in counseling and educational sessions.
Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment including arrangements for sober housing in a 34 house. Again, the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and methadone and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.
The health plan's determination is overturned. The requested inpatient detoxification 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 large quantities of substances that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. 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's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and methadone and supportive measures. The patient had associated clinical features that included lack of sober supports and severe psychosocial stressors including homelessness. Thus, the adult inpatient admission and continued detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do 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 or general medical complications such as seizures if 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, American Society of Addiction Medicine (ASAM) criteria, and the scientific literature, referenced below, and the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.