Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with a request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of heroin and alcohol; he had been using up to 18 bags of heroin with intravenous (IV) administration together with one pint of vodka daily. Additionally, he was using cocaine, one bag every other day. His substance use disorder had its onset in adolescence with the progression of the disease with severe opioid, stimulant and alcohol class substance use disorders. The patient had no history of withdrawal seizures or delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 0/67 and Clinical Opiate Withdrawal Scale (COWS) scale score of 3/48, reflecting minimal withdrawal symptoms together with normal vital signs. The patient had received one detoxification treatment in the past with no reported involvement in rehabilitation services or recovery groups.
There were no acute general medical or psychiatric issues in this case. He had recently had an infection in his neck at an injection site. Laboratory assessment and electrocardiogram (EKG) and a chest x-ray were unremarkable except for a urine drug screen that was positive and consistent with his history. He was tobacco dependent. He carried a diagnosis of diabetes mellitus treated with Metformin.
The mental status examination was free of severe symptoms such as thought disorder, mood disturbance, psychosis, cognitive impairment or perceptual disturbance. The patient was deemed to be motivated to enter detoxification treatment and he had minimal symptoms of withdrawal at the time of admission.
The patient was admitted and placed on a detoxification regimen with Methadone and Librium, comfort medications, as well as vitamin and nicotine replacement therapy. The detoxification was uncomplicated with regard to withdrawal management. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and the patient was discharged prematurely against medical advice with referral for clinically appropriate aftercare.
The case records, health plan documents, appeal documents, correspondence from the health plan and treatment facility, and the rationale for the denial of certification for coverage of the requested services, were reviewed. This case is a New York State mandated review with the application of New York (NY) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.
The health plan's determination is upheld.

The requested services could have been safely and effectively provided at a lower level of care. The patient in this case was using heroin, alcohol, and cocaine on a continuous daily or every other day basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested inpatient substance abuse servicesin keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) criteria and scientific literature, referenced below, as well as NY State OASAS LOCADTR 3.0 Guidelines.