Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction
Substance Abuse Inpatient

The patient is a male who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of opioid use disorder with use of two to three grams of heroin daily with intravenous (IV) administration. The patient was positive for cocaine on his drug screen. The patient had experienced severe opioid withdrawal in the past and had mild to moderately severe withdrawal at the time of admission with body aches, bone pain, nausea, abdominal cramps and diarrhea, as well as anxiety, irritability and restlessness with Clinical Opiate Withdrawal Scale (COWS) scale score of 11. He had experienced severe withdrawal symptoms in the past requiring detoxification including detoxification treatment, but denied history of withdrawal seizures, delirium tremens or blackouts. He also had extensive substance use disorder treatment in the past including at least two detoxification and inpatient rehabilitation treatment episodes, and he had participated in medication assisted treatment with methadone and Suboxone together with outpatient treatment.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone taper together with nicotine replacement therapy, and medical monitoring. Following his third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia. He had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He was treated with clonidine, Vistaril and gabapentin and as needed (prn) medications to address pain, nausea, diarrhea, anxiety, agitation and insomnia. Comfort medications and monitoring were continued. 
The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. Again, he was provided education and counseling during the remaining inpatient stay. The patient was discharged with recommendations for clinically appropriate aftercare, as well as recommendations for involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). He declined transfer for inpatient rehabilitation treatment and was discharged with referral for intensive outpatient program (IOP) level rehabilitation substance use disorder treatment.

The health plan's determination is overturned.

The proposed inpatient services and detoxification treatment and withdrawal management for severe use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care, as noted in the answer to question 1 above. The adult inpatient treatment of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorder and the associated psychosocial stressors and impairment of functioning. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and prn medications, as well as the availability of comfort medications and nicotine replacement therapy. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.