Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Inpatient
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented to the emergency department with a request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of heroin and cocaine use, as well as use of benzodiazepine (Xanax) and cannabis; he had been using up to ten bags of heroin daily with intravenous (IV) administration together with $40 worth of cocaine 1-2 times per week as well as intermittent use of cannabis and Xanax with 2-4 milligrams (mg). His substance use disorder had its onset as an emerging adult with initial use of alcohol and cannabis, and progression of the disease with subsequent use of cocaine and Xanax in his adolescence and diagnoses of opioid, stimulant (cocaine), cannabis, sedative-hypnotic-anxiolytic and alcohol use disorders with the latter in full remission. 

The patient was admitted and placed on a detoxification regimen with methadone, comfort medications, as well as vitamin replacement therapy. The detoxification was uncomplicated with regard to withdrawal management with no complaints other than persistent aches and anxiety that resolved on day 3 of the detoxification treatment episode, and he was described as having no apparent distress. The patient received counseling and education from the staff. His clinical course was uncomplicated with continued normal vital signs and the patient was discharged and converted to a rehabilitation bed as he neared completion of the detoxification with clinically appropriate recommendations for aftercare and plans for immediate referral/admission to a sister rehabilitation substance use disorder treatment facility. The subject under review is the medical necessity of the inpatient stay.

The requested benefit of detoxification treatment and withdrawal management and other medical services could have been safely and effectively provided with lower level services. The patient in this case was using heroin on a continuous daily basis together with stimulant, sedative-hypnotic-anxiolytic and cannabis class substances. He had recently received detoxification treatment and presented with mild withdrawal symptoms and normal vital signs. 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 despite a history of blackouts and inadvertent overdose with hospitalization for complications of substance use disorder. The patient was considered to be motivated for detoxification treatment and had access to rehabilitation substance use disorder services and treatment in the community. Again, 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 inpatient stay 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 Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines, referenced below.