Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant (Cocaine) class substances of abuse. The patient has a longstanding history of cocaine use with subsequent use of heroin. He reported a past history of severe withdrawal symptoms when attempting to curtail his use, and his substance use was interfering with his ability to work and take care of his family. He was using heroin with up to two bundles/twenty bags daily with intravenous (IV) administration together with $100 worth of cocaine also administered IV. Thus, he presented for detoxification treatment in the context of severe opioid and stimulant use disorders.
The patient has no history of a psychiatric disorder or treatment. He has no acute comorbid general medical issues other than a history of hepatitis C and cellulitis of the hand treated with antibiotics. His drug screen was positive and consistent with his history, but also included positivity for oxy (prescription opiates) which he denied using. He was medically screened and cleared for detoxification treatment including laboratory assessments that were negative or unremarkable.
The patient is high school educated with a vocational degree and employed, and lives with his family with three young children. There were no legal issues in this case.
Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms except for symptoms of anxiety and irritability associated with opioid withdrawal that included headache, nausea, and joint pain together with anxiety, irritability and insomnia reflecting mild withdrawal symptoms, and scoring a 10 on the Clinical Institute Withdrawal Assessment (CIWA) and 9 on the Clinical Opiate Withdrawal Scale (COWS) scales. He was generally motivated for treatment and described as cooperative with speech that was clear and organized thoughts that were free of delusions. There was no evidence for a thought disorder or cognitive impairment. The patient denied suicidal or homicidal ideation. Insight was limited with impaired judgment and poor control of impulses due to the addiction to heroin and cocaine.
The patient was admitted to detoxification treatment with comprehensive detoxification protocol with a five day methadone taper, and as needed (PRN) medications for comfort including medication to address pain and aches, anxiety and insomnia and nausea. The patient initially had mild symptoms of withdrawal that diminished in intensity but persisted throughout his inpatient stay until the last day when he felt better. While in detoxification treatment, the patient received counseling and education and attended groups, and received motivational enhancement therapy to encourage him to proceed to rehabilitation treatment.
The patient almost completed the detoxification protocol and was discharged against medical advice with referral for outpatient program (IOP) level substance use disorder rehabilitation treatment and recommendation for medication assisted treatment for the opioid use disorder, as well as recommended involvement with self-help recovery groups. He was discharged to home with family with plans to return to work.
The health plan's determination is overturned.
The treatment of this patient's substance use disorder did require the structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of comfort medications, as noted in the clinical summary.
The patient's history of opioid use and use of cocaine with daily use with IV administration, limited psychosocial supports and psychosocial stressors within several domains did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with achieving abstinence from opioid and cocaine use.
Thus, the patient did require the requested services, as it was foreseeable that the patient was unable to abstain from use of opioid or cocaine, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, the application of NY State OASAS LOCADTR 3.0 Criteria did warrant the admission and did also warrant the continued inpatient level care through discharge.