Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient detox stay 
The proposed treatment, continued inpatient detoxification and withdrawal management, was medically necessary for this patient.

The requested inpatient admission and substance use disorder treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin and cocaine together with cannabis (marijuana/hashish) on a daily continuous basis that did warrant 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. The patient has substantial mental health issues and severe psychosocial stressors that warranted inpatient level treatment. Moreover, the patient presented with withdrawal symptoms that persisted throughout his inpatient stay, and, the patient's social environment was not conducive to detoxification, and the patient's treatment occurred in the context of limited insight, impaired judgment and poor control of impulses with a chronic relapsing clinical course and history.

Thus, the continued adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of PRN medications. The patients history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorders, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient detoxification and withdrawal management was medically necessary and clinically appropriate in this case scenario, and is therefore a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant the continued inpatient level detoxification services thru discharge and did necessitate the continued monitoring that is provided with inpatient level treatment including the use of comfort medications together with counseling and educational sessions and peer support. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition with consideration of medication assisted treatment with methadone maintenance. Moreover, the admission and the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.