Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with a request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of heroin and alcohol; he had been using up to 1 bag of heroin with intranasal administration together with one liter of vodka plus beer daily.  His substance use disorder had its onset in adolescence with the initial use of alcohol and progression of the disease with subsequent use of heroin and diagnoses of severe opioid and alcohol class substance use disorders.
The patient has no history of withdrawal seizures or delirium tremens.  His referral was prompted by his desire to receive substance abuse treatment in the context of continued use of substances despite participating in a Methadone maintenance treatment program.  He indicated the desire to stop using heroin and other substances of abuse in the context of severe psychosocial stressors, including homelessness for the past 15 months and unemployment.  He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 3/67 with sweats, anxiety and restlessness together with normal vital signs.  The patient had received past detoxification treatments including the more recent treatment.
There were no acute general medical or psychiatric issues in this case.  He had recently had an infection in his right eye treated with an antibiotic ointment.  A laboratory assessment and chest x-ray were unremarkable except for a urine drug screen that was positive and consistent with a history including the presence of cocaine and benzodiazepine with the latter reflecting his recent detoxification treatment.  He was tobacco dependent with minimal tobacco use.  His Methadone dose was confirmed at 50 milligrams (mg) daily.
The mental status examination was free of severe symptoms such as thought disorder, mood disturbance, psychosis, cognitive impairment or perceptual disturbance.  The patient was deemed to be motivated to enter detoxification treatment, and he had minimal symptoms of withdrawal at the time of admission, as noted.
The patient was admitted and placed on a detoxification regimen with as needed (prn) dosing of Methadone with continuation of his maintenance dose of 50 mg and a Librium taper, comfort medications, as well as vitamin replacement therapy.  The detoxification was uncomplicated with regard to withdrawal management, though he required ongoing use of Clonidine for anxiety/agitation and Benadryl for insomnia.  The patient received counseling and education from the staff.  His clinical course was uncomplicated with continued normal vital signs, and the patient was discharged with clinically appropriate aftercare and immediate referral/admission to inpatient rehabilitation substance use disorder treatment.
The case records, health plan documents including case notes, appeal documents, correspondence from the health plan and treatment facility, and the rationale for the denial of certification for coverage of the requested services were reviewed.  This is a New York State mandated review with the application of 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.

The health plan's determination is upheld.

The requested services could have been safely and effectively provided at a lower level of care.  The patient in this case was using heroin while receiving methadone maintenance and using alcohol on a continuous daily basis.  There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services.  Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring.  There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol.  The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community.  Moreover, the patient had recently received detoxification treatment with discharge a few days prior to his presentation.  Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, referenced below, as well as NY State OASAS LOCADTR 3.0 Guidelines, referenced below.