Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction- Alcohol and Opioid
Treatment: Substance Abuse: Inpatient
The health plan denied the inpatient detoxification treatment as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient was admitted to acute inpatient level services for monitoring and detoxification and withdrawal management of alcohol and opioid use disorders. The patient was using up to 9 bags of heroin with intranasal administration, as well as daily use of alcohol with up to nine 12-ounce beers. The patient had experienced mild to moderately severe alcohol and opioid withdrawal at the time of admission with withdrawal symptoms that included joint pain, aches, nausea, sweats, and tremor, as well as anxiety, irritability, and insomnia. Case notes indicate several detoxification treatment episodes including one in the same month with completion.

The patient was placed on a detoxification regimen with a Librium and methadone taper, vitamin replacement therapy, and medical monitoring; the patient was tobacco dependent and offered smoking cessation and nicotine replacement. Following his third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. Vitamins were continued, as well as comfort medications and monitoring, and assistance with daily activities. Withdrawal symptoms and associated symptoms of agitation, anxiety, sweats gradually diminished. Mental status examination was free of severe symptoms such as mania or depression, psychosis, perceptual disturbance, or cognitive impairment, and he denied suicidal ideation or aggressive impulses. He had anxiety, irritability, and insomnia, as noted. Insight was limited and judgment impaired due to the addiction.
The patient was initially ambivalent about his treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. The patient was discharged with recommendations and referral for clinically appropriate aftercare, as well as recommendation for involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). 
The requested health service/treatment of Inpatient Detoxification, Withdrawal Management, and Stabilization Services is medically necessary for this patient. The treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders, and the associated psychosocial stressors and impairment of functioning. Withdraw symptoms were managed with tapering dosages of benzodiazepine and methadone requiring monitoring and as needed medications, as well as the availability of comfort medications and nicotine replacement and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment.  It was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care. Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer and determination is also consistent with New York State instruction concerning medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria and Guidelines, referenced below.