Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse admission
The insurer denied the Inpatient substance abuse admission.
The denial is upheld.

The patient is an adult male. He presented with a request for detoxification services less than one month after receiving detoxification treatment earlier in the year, as well as other detoxification and withdrawal management treatment episodes several times prior with referrals to rehabilitation services, but no follow up. The patient was using opioid (heroin), cocaine or crack cocaine, and alcohol on a continuous daily basis. He presented with a blood alcohol level of zero and mild symptoms of withdrawal with a COWS (clinical opiate withdrawal scale) scale score of 9 and CIWA (clinical institute withdrawal assessment) scale score of 7. He presented with normal vital signs and mild tremors, sweats, anxiety and motor agitation. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. The patient had no history of psychiatric disorders or treatment and no acute or chronic general medical problems; he was tobacco dependent at one pack per day. His substance use included up to 30 bags of heroin, $40 worth of cocaine, two to three pints of cognac on a daily continuous basis.

The patient was admitted for inpatient detoxification with plans for a Methadone and Librium taper. The patient's hospital course progressed without incident. Vital signs were consistently normal and the patient was in no apparent distress. The patient slept and received meals. His monitoring occurred without incident, and he attended group sessions and received counseling with recommendation for clinically appropriate aftercare. He received vitamin replacement therapy and prn (as needed) use of Vistaril.  He was discharged against medical advice without explanation, and referred for residential rehabilitation treatment.

The health plan's denial of coverage for the requested service was based on New York State LOCADTR (level of care for alcohol and drug treatment referral) Criteria not being met, and no serious withdrawal symptoms or complications of the opioid or cocaine or alcohol use disorders or other comorbidities. Also, COWS (clinical opiate withdrawal scale) and CIWA (clinical institute withdrawal assessment) scale scores were rated as mild and vital signs were normal indicating that residential level care was clinically appropriate in this case.

The treatment facility appealed on the basis of New York State LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria.

No, the Inpatient substance abuse admission was not medically necessary for this patient.
The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorders did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder. There was no co-occurring psychiatric disorder or psychiatric symptoms that would have warranted inpatient level treatment. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

Moreover, as the health plan asserts in the reason for denial, New York State LOCADTR (level of care for alcohol and drug treatment referral) Criteria were not met, and no serious withdrawal symptoms or complications of the opioid or cocaine or alcohol use disorders or other comorbidities were present in this case. Also, COWS (clinical opiate withdrawal scale) and CIWA (clinical institute withdrawal assessment) scale scores were rated as mild, and vital signs were normal indicating that residential level care was clinically appropriate in this case as the health plan recommends.

This answer is consistent with New York State LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive setting, contrary to the treatment facility appeal indicating that New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria were met. The patient displayed no serious disturbance of mental status. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted in the answer to question 2. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services, as the health plan asserts in the denial.