Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient
The insurer denied: Inpatient detox hospital admission
The denial is: Overturned in whole

The patient is a female who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe sedative-hypnotic-anxiolytic (benzodiazepine) and opioid (heroin and non-prescribed methadone) use disorders. She was using up to 15-20 bags daily of heroin together with 60 milligrams (mg) of non-prescribed methadone occasionally and use of Xanax with three mg at a frequency of one to two times per week. The patient had mild to moderate anxiolytic and opioid withdrawal at the time of admission with sweats, tremors, cold and hot flashes, flushing, anxiety, irritability, and insomnia. She reported severe withdrawal symptoms in the past requiring detoxification services on multiple occasions with a tendency to leave treatment prematurely and to relapse. 
The patient denied psychiatric hospitalization, or suicidal or self-harming behaviors. She has a history of unspecified depressive disorder and chronic insomnia without ongoing mental health treatment.
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 normal vital signs that remained normal throughout the inpatient stay. She was tobacco dependent.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone taper, vitamin replacement therapy, and medical monitoring; the patient was offered smoking cessation treatment and received nicotine replacement. Following her intake and admission, the patient began to participate actively in counseling and educational sessions, as her withdrawal symptoms diminished, and she was feeling better. However, she continued to report anxiety with craving and restlessness.
The patient was ambivalent about her treatment and required motivational techniques and counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. Again, she was provided education and counseling during the brief hospital stay. The patient was discharged against medical advice on the second hospital day, as the patient indicated that the dosing of methadone was not enough and that she was uncomfortable.

The subject under review is the medical necessity for the inpatient detox.

The health plan's determination is overturned, in whole.

The proposed inpatient services and detoxification treatment and withdrawal management for severe substance use disorders, and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. This patient's substance use disorders and clinical features and treatment dimensions did warrant the admission and the 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 co-occurring depressive disorder and associated psychosocial stressors and impairment of functioning. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and nicotine replacement and vitamin supplements. Seizure and fall precautions were provided with use of seizure prophylaxis with Depakote. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. 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.