Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction 
Treatment: Inpatient Substance abuse 

The insurer denied the inpatient substance abuse treatment. The denial is overturned in whole. 

The patient presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant (Cocaine) class substances of abuse. The patient has a history of Heroin use with subsequent use of Cocaine beginning in his early 30's. The patient was using Heroin with up to five bags daily with intravenous (IV) administration together with $10-20 worth of Cocaine also administered IV. Thus, the patient presented for detoxification treatment in the context of severe opioid and stimulant use disorders. 

The patient has a history of detoxification treatment episodes with relapse. The patient provided no history of psychiatric disorder or treatment. The patient has no acute co-morbid general medical issues other than a history of asthma. A drug screen was positive and consistent with history. 

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms except for symptoms of anxiety and irritability associated with opioid withdrawal that included headache, nausea, and joint pain together with anxiety, irritability and insomnia reflecting mild withdrawal symptoms. There was no evidence for a thought disorder or cognitive impairment. The patient denied suicidal or homicidal ideation. Insight was limited with impaired judgment and poor control of impulses due to the addiction to Heroin and Cocaine. 

The patient was admitted to detoxification with medications for comfort including medication to address pain and aches, anxiety and insomnia and nausea (Clonidine and Hydroxyzine). While in detoxification treatment the patient received counseling and education and attended groups, and received motivational enhancement therapy for encouragement to proceed to rehabilitation treatment. 

The patient almost completed the detoxification protocol and was discharged against medical advice. The patient received a recommendation for medication assisted treatment for the opioid use disorder which was declined, as well as recommended involvement with self-help recovery groups. The patient was discharged to home with family with plans to return for rehabilitation treatment at a different time. 

The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case presented with continuous daily use of Heroin and Cocaine in large quantities in the context of severe psychosocial stressors with unemployment and legal charges. 

The treatment of this patient's substance use disorders with detoxification and withdrawal management did require the structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and history and course of treatment. Additionally, the patient had a treatment history with relapses that supported the necessity for an inpatient level detoxification. Withdrawal symptoms were appropriately managed with tapering dosages of Methadone requiring monitoring and supportive measures including the use of Clonidine, Hydroxyzine, and comfort medications, as noted in the clinical summary. 

Thus, the patient did require a safe and effective detoxification treatment with Inpatient Detoxification and Withdrawal Management through discharge. Moreover, the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria did warrant the admission and did also warrant the continued inpatient level care through discharge with the clinically appropriate application of the NY State OASAS LOCADTR 3.0 Guidelines as referenced below.