Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. He was admitted to inpatient level services for detoxification treatment, stabilization and withdrawal management. The patient reported no past history of withdrawal seizures or delirium tremens. His self-referral was prompted by the desire to receive treatment for substance use disorder and to address acute symptoms of withdrawal. He had been treated at another facility earlier in the month, and his drug screen revealed evidence for methadone consistent with history of recent detoxification treatment. He reported using up to 20 bags of heroin daily with IV administration, and intermittent use of crack cocaine with up to $200 worth per week, as well as intermittent use of cannabis with one blunt one to three days per week in some months and at least monthly. At the time of presentation, the patient's COWS (clinical opiate withdrawal scale) score was at 8, reflecting mild withdrawal symptoms that included sweats, diarrhea, anxiety and insomnia.

The patient in this case was using heroin on a continuous daily basis together with intermittent use of cannabis and crack cocaine. The patient presented as cooperative and motivated to receive detoxification treatment in the absence of severe symptoms of opioid withdrawal. He had recently received detoxification treatment with no mention of whether he had relapsed. Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation or aggressive impulses at the time of admission. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical presentation was not serious enough to warrant inpatient level treatment or 24-hour monitoring. Additionally, the patient did not present with severe psychosocial stressors that would have posed a problem if detoxification treatment was provided in a less restrictive treatment setting at a lower level of care. Thus, the detoxification treatment (and referral/treatment for/with rehabilitation services) could have been effectively provided at a lower level of care, as the health plan asserts. 

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, as well as the clinically appropriate application of NY State OASAS LOCADTR 3.0 Guidelines/Criteria.

The Substance use disorder detoxification services and withdrawal management could have been safely and effectively provided at a lower level of care in this case scenario. Thus, the requested service of Substance use disorder inpatient admission for detoxification and other medical services are not reasonable in this case scenario. The patient's presentation and clinical features of substance use disorder did not warrant the intensity of inpatient level services or inpatient level structure or 24-hour monitoring in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines (NY State OASAS LOCADTR 3.0 Criteria/Guidelines), referenced below.