Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment 
The insurer denied the Inpatient substance abuse treatment.
The denial is overturned. 

The patient is an adult male who presented to the emergency department requesting detoxification treatment and was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin) and stimulant (cocaine) class substances. The patient had been using up to 14 bags of heroin with intravenous (IV) administration as well as four bags of cocaine. 

The patient had a longstanding history of substance use disorder. He had a history of prior detoxification treatment episodes with the last occurring five months prior to admission with relapses. His self-referral for treatment was prompted by multiple stressors including occupational, primary support, housing, social environment and other psychosocial domains, and, he had somatic complaints that included abdominal pain and nausea with withdrawal symptoms and a Clinical Opiate Withdrawal Scale (COWS) score of nine reflecting mild withdrawal symptoms from heroin including anxiety, irritability, nausea body aches, joint pain, sweats and tremors/shakes.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone, and as needed (PRN) medications for comfort, as well as vitamin replacement therapy. 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 education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal or near normal during his brief stay, and he was treated with lisinopril to address hypertension. 

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of methadone. Withdrawal symptoms remained mild and resolved after the first day of treatment. The patient did not complete the detoxification treatment and was discharged against medical advice (AMA). He accepted referral for outpatient detoxification and rehabilitation treatment. There were no complications during his inpatient stay. 

Yes, the proposed treatment, inpatient substance abuse treatment 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, together with cocaine with IV administration in large quantities on a daily continuous basis that did warrant the admission for inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol and brief stay; 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 a positive drug screen that was consistent with history and presented with co-morbid general medical conditions that included hypertension and type II diabetes mellitus. He had mild and persistent withdrawal symptoms through day #2, and, the patient's social environment was not conducive to detoxification 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 medications and other medical services. The patients 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 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, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and with New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.