Appeal type: Medical necessity
Decision: Overturned

The patient is a male who was referred from his methadone maintenance treatment program (MMTP) for emergency services and admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe sedative-hypnotic-anxiolytic (benzodiazepine), opioid (heroin and prescribed methadone) and cannabis use disorders. He was using heroin together with a daily dose of methadone at 50 milligrams (mg) per day, and he was using marijuana and large amounts benzodiazepines/Xanax with up to 8 mg daily. The patient had experienced mild to moderately severe anxiolytic and opioid withdrawal at the time of admission with chills, sweats, diarrhea and elevated blood pressure.
The patient denied psychiatric disorders or treatment including psychiatric hospitalization, or suicidal or self-harming behaviors.
There were no acute general medical issues in this case. Laboratory assessment was normal or unremarkable with a positive drug screen consistent with history, and abnormal vital signs that became normal throughout the inpatient stay. He was tobacco dependent at one-half pack per day use.
The patient is married with five children. He participates in a methadone treatment program, as noted. He denied trauma history or legal issues.
The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a Phenobarbital taper, vitamin and nicotine replacement therapy, nutritional supports and medical monitoring. Following the third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better despite persistent symptoms of malaise and insomnia. Comfort medications were continued including Clonidine and Vistaril.
The patient received motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition back to his community MMTP. He did continue with detoxification treatment and was maintained on fall and seizure precautions. The patient was discharged with recommendations for clinically appropriate aftercare with plans for continued use of methadone, as well as recommendations for continued mental health treatment and involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). He was discharged in satisfactory condition.
The subject under review is the medical necessity of the inpatient admission and continued stay for detoxification treatment.

The health plan's determination is overturned.

The continued inpatient services and detoxification treatment and withdrawal management for severe substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care, as noted in the answer to question 1 above. This patient's substance use disorders and clinical features and treatment dimensions did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the continued use of Xanax and cannabis in the context of methadone maintenance treatment. Withdrawal symptoms were managed with tapering dosages of phenobarbital and continued use of methadone requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and nicotine replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition back to rehabilitation substance use disorder treatment in the community. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.