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 a adult male requesting detoxification treatment. He was admitted to acute inpatient level care beginning in order to address substance use disorder with opioids (heroin), alcohol, and stimulant (cocaine) class substances, as well as receiving 100 mg (milligrams) of methadone daily in a methadone maintenance treatment program for opioid use disorder. The patient had been using up to 20 bags of heroin per week together with one-half pint of liquor and two 6-packs of 8 beers per day, and intermittent use of crack cocaine. He has a history of withdrawal seizures and delirium tremens and blackouts, and had a recent history of accidental overdose. He had a history of prior detoxification and substance use disorder treatments with current medication assisted treatment of the opioid use disorder, as noted. His self-referral for treatment was prompted by multiple stressors including housing, occupational, primary support, social environment and other psychosocial domains.

The patient has a remote history of psychiatric disorder best characterized as unspecified depression with psychiatric hospitalization. He presented without acute co-morbid general medical issues. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history. He has a history of hepatitis C positivity and dyslipidemia. The patient is an every-day smoker and tobacco dependent.

The patient's evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. The patient was generally motivated for treatment and described as cooperative with a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and agitation, in part due to the onset of alcohol withdrawal. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Librium and continued use of methadone, and clonidine as needed, and prn (as needed) medications for comfort, as well as vitamin and nicotine 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 psycho-educational sessions to motivate the patient to proceed to rehabilitation treatment and continue with the methadone program. Vital signs remained normal during the stay.

Yes, the 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 and alcohol on a daily basis while receiving methadone together with cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol. 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's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms and craving during the time interval under review 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/availability of prn medications. The patient's 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 continued detoxification and withdrawal management were to have been attempted at a lower level of care. Moreover, the patient has a history of severe withdrawal including withdrawal seizures and delirium tremens from alcohol. Therefore, medical necessity for the requested services is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below. This answer is in keeping with New York State instruction for medical necessity reviews, including the application of the NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care determination) Tool in this case that requires the patient in this scenario default to the higher level of care.