Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient admission.

The insurer denied the Inpatient admission.  The denial is overturned. 

The patient is a male requesting detoxification treatment and admitted to acute inpatient level care in order to address substance use disorder with opioids (heroin), alcohol, and stimulant (cocaine) class substances, as well as use of sedative-hypnotic-anxiolytic class drug of abuse (Xanax).  The patient had been using up to five bags of heroin together with six to eight beers and occasional use of crack cocaine.  He was using up to 6 mg (milligrams) of Xanax on a daily continuous basis.  He denied history of withdrawal seizures or delirium tremens or blackouts and denied history of accidental overdose.  He had a history of prior detoxification and substance use disorder treatment with Suboxone/medication assisted treatment of the opioid use disorder.  His self-referral for treatment was prompted by multiple stressors including occupational, primary support, social environment and other psychosocial domains.

The patient has no history of psychiatric disorder and presented without acute co-morbid general medical issues.  Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history.  He has a history of hepatitis C positivity.  The patient is an every-day smoker and tobacco dependent with one pack per day use and 30 pack years.

The patient is single and unemployed with housing.  He did not report trauma or abuse history, or legal issues.  He had social supports from family.

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms.  The patient was generally motivated for treatment and described as cooperative with a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and aches due to the onset of opioid and benzodiazepine withdrawal.  Speech was clear with organized thoughts that were free of delusions.  There was no evidence for a thought disorder, mania, psychosis or cognitive impairment.  The patient denied suicidal or homicidal ideation and did not have perceptual disturbances.  Insight was limited with impaired judgment and poor control of impulses.  His withdrawal symptoms included anxiety, irritability, nausea, rhinorrhea, sweats, hot and cold flashes, yawning, tremor and body aches.  COWS (clinical opiate withdrawal scale) score was at 17 indicating moderately severe withdrawal symptoms.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Suboxone, and clonidine as needed, and prn (as needed) medications for comfort, as well as vitamin replacement therapy.  He had the availability of nicotine replacement and smoking cessation education.  The program provided for case management with referral to sober housing and access to rehabilitation treatment that included comprehensive evidence-based treatments.  During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and involvement with counseling and milieu activities including peer support and psycho-educational sessions to motivate the patient to proceed to rehabilitation treatment.  Vital signs remained normal during the stay. 

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of Suboxone.  Withdrawal symptoms gradually diminished, but persisted throughout the stay with aches, pain, anxiety and insomnia.  By the time of discharge, the patient reported mild withdrawal symptoms.  He did not complete the detoxification protocol and was discharged from inpatient level care against medical advice (AMA), and was given a prescription for Suboxone with referral for substance use disorder rehabilitation treatment and continued medication assisted treatment and recommendation for involvement in peer-supported recovery groups.

Yes, the Inpatient admission  was medically necessary for this patient.

The requested Inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using heroin and Xanax on a daily basis together with alcohol and crack cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient had persistent withdrawal symptoms, and the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn (as needed) medications.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, and this answer is in keeping with New York State instruction for medical necessity reviews including the application of the NY (New York) State OASAS (Office of Alcoholism and Substance Abuse Services) LOCADTR (level of care for alcohol and drug treatment referral) Tool in this case that requires the patient in this scenario default to the higher level of care.

The requested benefit of Inpatient Admission is medically necessary and clinically appropriate in this case scenario and is therefore a covered service.  The patient's clinical features and treatment dimensions did warrant the admission and continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications, together with counseling and educational sessions and peer support.  Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition.  Moreover, the admission and the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services, as noted in the answer earlier. Thus, the Inpatient Admission should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM (American Society of Addiction Medicine) Criteria and the New York State OASAS (Office of Alcoholism and Substance Abuse Services) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines, referenced below.