Appeal type: Medical necessity
Decision: Overturned

The patient  presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid (heroin), and cannabis (marijuana) class substances of abuse. Also had a history of prior substance use disorder treatment including medication assisted treatment, but relapsed and was using large quantities of alcohol on a continuous daily basis with up to ten 50 ml bottles ("airline bottles") together with three bundles of heroin daily, as well as intermittent and frequent use of cannabis. 

At the time of presentation, the patient was requesting referral for rehabilitation substance use disorder treatment. Patient denied current legal issues, but had spent 26 years in prison with release. Patient was employed with job jeopardy and reported severe psychosocial stressors within the primary support, social environment, occupational and economic/financial domains. The patient reported functional decline as the substance abuse/disease had progressed which prompted self-referral for detoxication treatment. The patient provided no past history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms. Patient was medically screened and admitted for inpatient level detoxification with plans for a five day detoxification treatment with Librium and methadone and supportive measures. Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment (CIWA) scale scores initially showed mild withdrawal symptoms with a score of 6 with subsequent increases to 13 and 7 at the time of  psychiatric evaluation. Withdrawal symptoms and signs included sweats, nausea and abdominal cramps, joint and bone pain, and anxiety/irritability, as well as insomnia. Drug screen was consistent with history. The patient has no history of psychiatric disorders or suicidal behavior. The patient has chronic medical conditions that include von Willebrand disease associated with hemophilia, asthma treated with a steroid inhaler and rescue inhaler, and hypertension treated with amlodipine. The patient was tobacco dependent. The patient was admitted for inpatient level detoxification treatment with detoxification protocol. Patient received tapering dosages of Librium and methadone and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, agitation, and insomnia. The patient's hospital course progressed without incident, but  did require prn medications. Vital signs normalized on day two of the hospital stay. Patient was socially withdrawn initially, but participating in counseling and educational sessions. The patient left treatment prior to completion of the detoxification with an AMA discharge (against medical advice) and recommendations for clinically appropriate aftercare. The health plan's determination of medical necessity is overturned. The requested service of inpatient detoxification is clinically appropriate, medically necessary and warranted in this case scenario. 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 service is in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of American Society of Addiction Medicine (ASAM) Criteria and application of NY State OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines. The patient in this case was using large quantities of alcohol and heroin on a daily continuous basis together with 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. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium, methadone and supportive measures. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses. Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring.