Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male. He presented to the emergency department 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 Fentanyl and heroin with intravenous administration together with daily use of Xanax and/or Valium. He also reported use of "olly," resulting in a 
prolonged period of psychosis. He has a history of withdrawal seizures and hallucinations or delirium tremens. He had a history of prior detoxification and substance use disorder treatments with relapses. His self-referral for treatment was prompted by multiple stressors and general health concerns. His presentation included early withdrawal symptoms and signs, visual hallucinations, and general medical complications related to intravenous drug use.
The patient presented with acute comorbid general medical issues including a malnourished state and cellulitis with an abdominal abscess requiring irrigation and debridement and antibiotics. He was tobacco dependent. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history. He had a chest X-ray and multiple electrocardiograms due to ongoing concern with cardiac ischemia. The patient is homeless and unemployed, living under a bridge. The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Valium and Suboxone and as-needed medications for comfort, as well as antibiotics. He was discharged one day early against medical advice with referrals for clinically appropriate aftercare and plans to pursue medication assisted treatment for the opioid use disorder and long-term rehabilitation services. The health plan's denial of coverage was based on medical necessity and MCG (Milliman Care Guidelines) Criteria pertaining the substance-related disorders indicating that there was no risk for complicated withdrawal or abnormal vital signs. The appeal was based on the clinical features of the case including history of complicated withdrawal and presentation with acute medical issues and visual hallucinations. The appeal asserted that the patient could not have been safely managed with lower-level care in a less restrictive treatment setting.

The inpatient admission was medically necessary.

The requested Inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin and Fentanyl with intravenous administration together with Xanax and/or Valium on a daily continuous basis with recent use of "olly," complicating the clinical presentation. This did warrant inpatient level hospital care with 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 had acute medical issues requiring monitoring and evaluation and treatment as indicated in the clinical summary. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the 
patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published societal guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below. Therefore, the inpatient admission was medically necessary.