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 in the past without benefit or sustained sobriety; he indicated that he wanted detoxification treatment for his use of heroin with up to two bundles used daily with intranasal administration (snorting). He has an 18 year history of opioid use with limited treatment episodes and serious legal issues that resulted in a decline in functioning and incarceration for various offenses beginning at an early age.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a methadone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. He was prescribed Lexapro and Seroquel as well as prn doses of Vistaril. The patient had persistent symptoms of withdrawal scoring a 15 on the COWS scale on hospital days two, with persistent symptoms on day three and four when his withdrawal symptoms diminished; he tolerated the taper of methadone and was able to participate in counseling and educational group sessions. The day following his last dose of methadone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. Again, while in detoxification treatment the patient continued to receive counseling and education and attended groups and was adherent to his medication regimen with the Seroquel and Lexapro as well as hydrochlorothiazide (HCTZ) that was continued to address his hypertension.
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 psychiatric disorders and primary care.

The health plan's determination is overturned, in whole. 

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 methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications, as noted in the clinical summary. The patient's history of opioid use despite receiving medication assisted treatment with Suboxone, limited psychosocial supports and psychosocial stressors within several psychosocial domains did reflect the seriousness of the substance use disorder. Moreover, the patient presented with co-occurring mood and anxiety disorders and recent general medical problems resulting in a surgical procedure one month prior to admission. The case was therefore complicated with co-occurring disorders and co-morbidity.
Thus, the patient did require a safe and effective detoxification treatment with Continued Inpatient Detoxification and Withdrawal Management for the time interval under review thru discharge, as it was unlikely 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 NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, the continued inpatient level care through discharge is supported as medically necessary with the clinically appropriate application of the LOCADTR Guidelines.