Appeal type: Medical necessity
Decision: Overturned

The patient is a male who presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient has participated in a medication assisted treatment (MAT) program with Suboxone which he was only taking sporadically; he indicated that he wanted to come off of Suboxone, as well as receiving detoxification treatment for his use of heroin with up to 6 bags used daily with intranasal administration (snorting). He had ten years of sobriety following ten years of incarceration in prison but had relapsed twice in 2018 and again in 2019 despite being on probation and participating in outpatient treatment with Medicated-Assisted Treatment (MAT).

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a three day Suboxone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. The patient had persistent and mild symptoms of withdrawal scoring an 8 on the COWS scale on hospital days two, three and four, but the patient tolerated the taper of Suboxone. The day following his last dose of Suboxone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. While in detoxification treatment the patient continued to receive counseling and education and attended groups.
The patient completed the detoxification protocol and was discharged with referral for rehabilitation substance use disorder treatment, and with recommendations for smoking cessation, as well as recommended involvement with recovery groups and follow-up for clinically appropriate treatment of his co-occurring depressive disorder and primary care.

The health plan's determination is overturned.

The continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of Suboxone 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 recent relapses while receiving MAT, limited psychosocial supports and psychosocial stressors within several domains including risk for re-incarceration, and risk for relapse in view of his recent relapses did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with addiction to opioids.

Thus, the patient did require a safe and effective detoxification treatment with continued inpatient services as it was foreseeable that the patient was unable to abstain from use of heroin, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, using the of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, the patient did warrant the continued inpatient level care through discharge with the clinically appropriate application of the LOCADTR Guidelines.