Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction - Substance Abuse/Addiction
Substance Abuse Inpatient

The patient is a male who received inpatient substance abuse treatment related to diagnoses of alcohol withdrawal, cocaine use disorder, cannabis use disorder, and sedative, hypnotic, or anxiolytic use disorder. The patient was also stated to have a diagnosis of attention deficit hyperactivity disorder (ADHD). Urine drug screen  was positive for opiates, cocaine, benzodiazepines, methamphetamine, and barbiturates. The patient reported using heroin 25 bags per day,  4 milligrams (mg) of Xanax per day, and non-prescribed methadone 20 to 30 mg per day one to two times per week.
Clinical history was significant for multiple past episodes of substance use disorder treatment including detoxification and rehabilitation level of care. Medical history was significant for hepatitis C and negative for seizures, asthma, hypertension, heart disease, and diabetes. He had a history of treatment for ADHD. There was no surgical history. He denied any history of psychiatric hospitalizations. He denied any suicidal or homicidal ideation.
On admission, the patient reported nausea, trouble sleeping, anxiety, yawning, tremors, irritability, diarrhea, headaches, abdominal pain, rhinitis and teary eyes. In separate documentation, the patient also reported in the last 12 months having diarrhea and vomiting as well as insomnia and lightheadedness. The patient was placed on detoxification protocols for both opioids and benzodiazepines. Initial Clinical Institute Withdrawal Assessment (CIWA) was 16 and Clinical Opiate Withdrawal Scale (COWS) was 13.
The subject under review is the medical necessity of the inpatient substance abuse treatment.

The health plan's determination is overturned.

The patient did have serious medical symptoms that needed to be managed in and inpatient setting to be effective. Benzodiazepines were the substance the patient was using with the greatest potential for harm. Opioids were also being used, creating a difficult management situation given potential interactions between opioids and benzodiazepines and their associated withdrawal protocols. The patient clearly met criteria for multiple substance use disorders and did not have any substance use disorders in full remission. Use of 4 mg of Xanax per day put the patient at risk for seizures from withdrawal that could be life-threatening. His withdrawal management from both opioids and benzodiazepines could not have been safely managed at a lower level of care. 24 hour medical supervision was needed. The patient was not adequately performing responsibilities in work, social, and family roles. The patient was poorly connected to a support network. He could not manage triggers. He could not be managed in a lower level of care setting.
Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool, the appropriate Level of Care is inpatient rehabilitation.
Benzodiazepines have a potentially life-threatening withdrawal syndrome. Additionally, the situation was complicated by opioid withdrawal and the interactions between withdrawal protocols for sedative and opioid use disorders. The patient had a high risk of relapse and poor supports.
Inpatient level of care was medically necessary.