Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Inpatient Detoxification Admission.

The insurer denied the Inpatient Detoxification Admission.  The denial is overturned.

The patient is an adult male. He presented for detoxification and withdrawal management. The patient has a history of severe substance use disorders beginning in early adolescence with daily use of alcohol, stimulants (cocaine), and cannabis (marijuana) class substances of abuse. He has a several decade history of substance use with a chronic relapsing course with at least 10 relapses and escalation of use with regard to quantity and frequency of use. He was using up to one liter of liquor on a continuous daily basis together with two blunts of marijuana and $80 worth of cocaine daily.

The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Valium and replacement of vitamins, as well as nicotine replacement for tobacco dependence with the availability of counseling and comfort medications and prn (as needed) medications prescribed for pain, anxiety, and insomnia that included melatonin, trazodone and gabapentin.

The patient's hospital course progressed without incident. Vital signs remained abnormal with blood pressure variability, and the patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished, but persisted throughout his hospital course with a CIWA (clinical institute withdrawal assessment) scale score of 5 on the date of completion of the detoxification protocol. He was participating in counseling and educational sessions with introduction of 12-step self-help meetings. During the last two days of his treatment, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment. Arrangements were being made for a direct referral or step down to rehabilitation substance use disorder treatment.

The patient was discharged with recommendations for continued medication assisted treatment with gabapentin and involvement with AA (alcoholics anonymous) and NA (narcotics anonymous) self-help groups for support of a recovery.

The health plan denied coverage for the requested services on the basis of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria indicating that the patient could have been provided services with lower-level care such as outpatient treatment. The denial determination referenced a lack of comorbid general medical, psychiatric and neurological comorbidity and that there were no severe withdrawal symptoms or medical complications of the substance use disorders that would require inpatient level services.

The treatment facility indicated that the requested services were medically necessary in keeping with New York State LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Guidelines for the treatment of substance use disorders. The appeal referenced the lack of a reasonable recovery environment or supports, high risk for relapse and high risk for medical complications of withdrawal in the context of the quantity and frequency and duration of substance use and no past exposure to treatment, as well as a lack of insight and knowledge about a recovery process requiring motivational enhancement.

Yes, the Inpatient Detoxification Admission was medically necessary.

No, the health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested benefit of inpatient detoxification and withdrawal management is clinically appropriate, medically necessary and warranted in this case scenario, and should therefore be covered by the health plan. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower- level services. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of ASAM (American Society of Addiction Medicine) Criteria and application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria, referenced below.

The requested health service/treatment of admission and continued stay at the inpatient detoxification facility is medically necessary for this patient.

The requested benefit of inpatient detoxification 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 large quantities of alcohol on a daily continuous basis together with cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. 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.

Medical necessity 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, and, New York State instruction for medical necessity reviews including the appropriate application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria-referenced below.