Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male. He presented for detoxification and 
withdrawal management for opioid (Fentanyl) and Stimulant (cocaine) class substances of abuse. He had received past substance use disorder treatments and was participating in a methadone maintenance treatment program with 110 milligrams of methadone daily. The patient had a history of psychiatric disorders and past treatment for anxiety and depression but was taking no psychotropic medications. His substance use included up to 1-2 bags of Fentanyl and 1 bag of cocaine daily with IV (intravenous) and/or IN (intranasal) administration. His self-referral was prompted by his parole officer who mandated the treatment. The patient was medically screened and admitted for inpatient level detoxification with use of continued methadone, vitamin replacement therapy and comfort medications. 
On Mental Status Examination, the patient was cooperative with good eye contact. Speech was 
clear and thought production was linear and logical. There were no severe symptoms on mental 
status examination such as thought disorder, cognitive impairment, severe mood disturbance, 
psychosis or perceptual disturbance, or suicidal ideation.
The patient presented with anxiety and complaints of insomnia addressed with Vistaril prn (as 
needed). He had fair control of his impulses. The CIWA (clinical institute withdrawal 
assessment) and COWS (clinical opiate withdrawal scale) scale scores were both at a zero.
The patient was admitted for inpatient detoxification. The patient's hospital course progressed 
without incident until the day of discharge. Vital signs were consistently normal and the patient 
was in no apparent distress. The patient slept with the use of prn Vistaril. His monitoring 
occurred without incident, and he attended group sessions and received counseling with 
recommendation for clinically appropriate aftercare to include rehabilitation treatment. He was 
discharged against administratively with referral back to his outpatient clinic and 
recommendations to resume his involvement with 12-step recovery groups and continued use of methadone, as well as quarantine in a shelter. The health plan denied coverage of the admission based on New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3 Criteria indicating that the patient was not acutely ill, had no risk for severe withdrawal symptoms or general medical complications with no psychiatric symptoms warranting inpatient level services. The denial determination indicated that the patient could have been treatment with lower-level services such as residential care. 

The Inpatient Detoxification Admission was not medically necessary.

The inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not warrant the structure of an inpatient setting or 24-hour monitoring with every 6-hour nursing monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder. There was no co-occurring psychiatric disorder or psychiatric symptoms that would have warranted inpatient level treatment. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The patient had a working knowledge of substance use disorder treatment with a past history of treatment including involvement in a methadone program. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary. This answer is consistent with New York State LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria.