Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder.
Treatment: Inpatient Rehabilitation Admission.
The insurer denied the Inpatient Rehabilitation Admission.
The denial is overturned.

The patient is a female who presented for detoxification treatment and was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using heroin with intravenous administration together with Xanax. She has no history of withdrawal seizures or delirium tremens. She had a history of multiple prior detoxification treatment episodes and had past exposure to substance use disorder treatments with relapses and continued use of heroin and Xanax. 

The patient has a history of psychiatric disorder with unspecified anxiety and depressive disorders. There was no mention of general medical issues except for hepatitis C related to the intravenous drug use. The patient's initial assessment included a Clinical Opiate Withdrawal Scale (COWS) score of nine and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of ten reflecting mild to moderate withdrawal symptoms that included tremor, chills, sweats, nausea and abdominal cramps, headache, joint pain and fatigue.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone and detoxification protocol to address the comorbid use of Xanax and as needed (PRN) medications for comfort. 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 other therapeutic activities including initial work on relapse prevention, and educational sessions to motivate the patient to proceed to rehabilitation treatment. By the second day of detoxification treatment the patient continued to display withdrawal symptoms with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of nine and Clinical Opiate Withdrawal Scale (COWS) score of eight despite receiving treatment including methadone. The patient completed the detoxification treatment without complication, and she was discharged with clinically appropriate aftercare and immediate transfer for rehabilitation treatment and plans to address the co-occurring anxiety and depressive disorders that were thought to be triggering her substance use.

The denial was on the basis of 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 severe withdrawal symptoms, no past severe withdrawal symptoms, no safety issues, and, access to sober supports as well as prior detoxification treatment, the month prior to presentation. The denial also indicated that residential level care was the appropriate in this case.

The appeal is on the basis of the clinical features of the case including the high-risk use of heroin, the evidence for moderately severe withdrawal from both substances of abuse with persistent withdrawal symptoms, and the need to develop a relapse prevention plan that included planning to address the anxiety and depression. The appeal was argued that the patient met New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria for inpatient level detoxification and monitoring and withdrawal management based on the presenting clinical features and history of substance use.

The issue under review is inpatient detoxification and withdrawal management and other medical services,

Yes, the proposed treatment, inpatient substance abuse treatment was medically necessary for this patient.
The patient in this case was using heroin, together with Xanax, 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 following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient 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, as well as high-risk behaviors noted in the appeal.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorders 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. The patient's history of substance abuse reflects the seriousness of the substance use disorders and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or complications if the detoxification and withdrawal management were to be attempted at a lower level of care. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, the 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.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested benefit of inpatient substance abuse treatment is medically necessary and clinically appropriate in this case scenario, and is therefore a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications, together with counseling and educational sessions and peer support. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition though the patient did discharge against medical advice. The requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including the American Society of Addiction Medicine (ASAM) Criteria and the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below.