Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse/Addiction. 
Treatment:  Inpatient admission. 

The insurer denied inpatient admission.  The health plan's determination is overturned in whole.

The patient is a male, who was admitted to acute inpatient level services for monitoring and detoxification and withdrawal management of opioid use disorder with use of up to ten bags of heroin together with $20 worth of cocaine with intravenous (IV) administration and alcohol use with up to one pint of liquor at least three times per week.  The patient was participating in a methadone maintenance treatment program (MMTP) with a methadone dose of 80 milligrams (mg) daily.  He had struggled to remain abstinent of substances of abuse despite treatment with MMTP.  The patient was medically screened and was positive for opioids and cocaine on his drug screen.  The patient had experienced severe opioid withdrawal in the past and had mild alcohol withdrawal at the time of admission with tremors, nausea, irritability, anxiety and insomnia with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 9.  He had experienced severe withdrawal symptoms in the past requiring detoxification including detoxification treatment, but denied history of withdrawal seizures, delirium tremens or blackouts.

The patient had co-occurring psychiatric disorders that included bipolar disorder with most recent episode depression and an unspecified anxiety disorder with current outpatient mental health treatment that included Trintellix, Seroquel and doxepin.  He had no history of psychiatric hospitalization or suicidal or self-harming behaviors and denied history of overdose.

The patient readily engaged in treatment that included counseling and educational sessions and use of motivational techniques including case management that focused on working toward a safe and clinically appropriate discharge plan and disposition.  Again, the patient was provided education and counseling during the remaining inpatient stay.  The patient was discharged after completion of the detoxification treatment with recommendations for clinically appropriate aftercare, as well as recommendations for involvement in 12-step recovery meetings with Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).  He planned to continue with the methadone maintenance treatment program and his mental health clinician with plans to return for rehabilitation substance use disorder treatment to address the co-morbid substance use disorders.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient admission was medically necessary for this patient.

The adult inpatient treatment of this patient's substance use disorders 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 impairment of functioning.  Withdrawal symptoms were managed with tapering dosages of Librium and continued use of methadone requiring monitoring and PRN ("pro re nata" or "as needed") medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy.  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 and continue with MMTP.  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 treatment were to be attempted at a lower level of care. 

Medical necessity for the admission and the continued inpatient services is met in this case and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below.  This answer and determination is also consistent with the application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines, referenced below.