Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Admission
The insurer denied: Inpatient Substance Abuse Admission
The denial is overturned.

The patient is an adult male who presented for detoxification treatment, was medically screened, and admitted to acute inpatient level care. The patient had been using three 24-ounce beers together with up to 10 bags of heroin with intravenous administration, 20 dollars' worth of cocaine with intravenous administration, 2 to 4 milligrams of Xanax, as well as 2 to 3 marijuana joints. He has no history of withdrawal seizures or delirium tremens. The patient had a history of prior detoxification treatment episodes and substance use disorder treatments with relapses. His self-referral for treatment was prompted by multiple stressors and general health concerns including risk of losing his housing. The patient has no history of psychiatric disorder and no history of psychiatric hospitalization. The patient presented without acute co-morbid general medical issues. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history and history of hepatitis C positivity.
Insight was limited with impaired judgment and poor control of impulses. His onset of withdrawal symptoms included anxiety, motor agitation, sweats, body aches, abdominal pain, nausea and diarrhea, and irritability, scoring a 10 on the Clinical Institute Withdrawal Assessment (CIWA) scale and 8 on the Clinical Opiate Withdrawal Scale (COWS). The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Ativan and Methadone and as needed (PRN) medications for comfort, as well as vitamin replacement therapy. The program provided for case management with referral 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 unit activities including peer support and educational sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal during 
his inpatient stay. The patient completed four days of the detoxification treatment and was discharged against medical advice with referrals for clinically appropriate aftercare.
Denial Reason: The denial was based on medical necessity and New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that there was no serious withdrawal or general medical or psychiatric issues warranting inpatient level services.

The requested health services, inpatient substance-related services with withdrawal management and detoxification treatment, was medically necessary for this patient.

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 alcohol and Xanax and cocaine and cannabis (marijuana) on a daily continuous basis that did warrant 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. He had persistent withdrawal symptoms, 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 as needed (PRN) medications. 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 New York State instruction for medical necessity reviews including the appropriate application of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Tool that requires the patient in this scenario default to the higher level of care.