Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of opioid use disorder. The patient was also using alcohol cocaine on a daily basis. The patient had experienced severe opioid withdrawal in the past and had mild to moderately severe withdrawal at the time of admission with chills, tremors, body aches, nausea and diarrhea, and rhinorrhea, as well as anxiety, irritability and restlessness with Clinical Opiate Withdrawal Scale (COWS) scale score of 11. He had experienced severe withdrawal symptoms in the past requiring detoxification including detoxification treatment and nine days of rehabilitation treatments in the past year with relapse.
The patient had a co-occurring psychiatric disorder that included post-traumatic stress disorder (PTSD) with no current treatments. He denied psychiatric hospitalization, or suicidal or self-harming behaviors.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone taper together with vitamin replacement therapy, and medical monitoring. Following his third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished and he was feeling better. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia. He had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He was treated with Benadryl and as needed (PRN) medications to address pain, anxiety, agitation insomnia. Vitamins were continued, as well as the comfort medications and monitoring, and assistance with daily activities.

The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. He did continue with detoxification treatment and was maintained on fall and seizure precautions. The health plan's determination is overturned.

The proposed inpatient services and detoxification treatment and withdrawal management for severe polysubstance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. 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 the associated psychosocial stressors and impairment of functioning. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and PRN medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. 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.