Appeal type: Medical necessity
Decision: Overturned

The patient is a male who was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine) and opioid (heroin and street methadone) use disorders. He was using up to 10 bags daily of heroin, alcohol with a binge pattern of use, and one gram of cocaine every two days. The patient had experienced moderately severe alcohol and opioid withdrawal in the past and was beginning to withdrawal from opioids and alcohol at the time of admission. The patient has a diagnosis of co-occurring depressive disorder and acute stress disorder. He denied psychiatric hospitalization, or suicidal or self-harming behaviors.

Admission through discharge from detoxification treatment, symptoms included agitation, anxiety, restlessness, yawning, tremor, headache and body aches, rhinorrhea, and nausea. His demeanor improved as he underwent detoxification treatment except for nicotine withdrawal symptoms and craving that were addressed with as needed (prn) medications. Again, he was provided education and counseling during the remaining inpatient stay. The patient was discharged with immediate transfer to inpatient rehabilitation substance use disorder services with recommendations for medication assisted treatment with naltrexone/Vivitrol and clinically appropriate aftercare, as well as recommendation for involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA).

The health plan's determination is overturned.

The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol and opioid use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders did require 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 continued presence of craving and moderately severe withdrawal symptoms including. Withdraw symptoms were managed with tapering dosages of benzodiazepine and methadone requiring monitoring and as needed (prn) medications, as well as comfort medications, and medication to address the craving that included nicotine replacement therapy and motivational enhancement therapy to prepare the patient for a transition to rehabilitation services and consideration of medication assisted treatment. Thus, the patient did require a safe and effective detoxification with continued withdrawal management during the time frame under review, as 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 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 is also consistent with Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines, referenced below.