Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Medically Supervised Inpatient Detoxification Admission.
The insurer denied the Medically Supervised Inpatient Detoxification Admission.
The denial is overturned.

The patient is a male who presented voluntarily for detoxification treatment and was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid, cannabis, and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using up to eight bags of heroin with intravenous (IV) administration together with daily misuse of prescribed Xanax or Klonopin, and one marijuana blunt.  He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatments; he indicated that he had a history of leaving treatment prematurely and had at least four relapses with only eight months of sobriety since his onset of substance use in adolescence. His use of heroin had begun several years prior. His self-referral for treatment was prompted by multiple stressors and general health concerns.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone and as needed (pro re nata - prn) medications for comfort, as well as vitamin replacement therapy and the availability of nicotine replacement. The program provided for case management with referral and access to rehabilitation treatment that included comprehensive evidence-based treatments. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and, involvement with unit activities including peer support and education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs were intermittently elevated and his withdrawal symptoms persisted with intense craving. The patient left against medical advice with referral for clinically appropriate follow up.

The denial determination was on the basis of New York State NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient had no serious withdrawal symptoms, no safety issues, no psychiatric or general medical comorbidity and was motivated. The denial indicated that the patient could have been treatment with residential level care.

The appeal noted persistent withdrawal symptoms with elevated blood pressure determinations and intense craving in a patient with a history of relapses and high-risk use of intravenous (IV) opioids and benzodiazepines. The appeal argued that New York State NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were met for inpatient level detoxification and withdrawal management.

The issue under review is Inpatient Level Detoxification and Withdrawal Management and other medical services.

Yes, the proposed treatment is medically necessary for this patient.
The requested inpatient admission and continued 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, together with other substances of abuse on a daily continuous basis that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the stay.  Moreover, the patient had a positive drug screen that included opioids and benzodiazepines, as well as tetrahydrocannabinol (THC) indicating high-risk use. He displayed persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the 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 as needed (pro re nata - prn) medications with monitoring. The patient's history of substance abuse (frequency and quantity) together with the 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, as the appeal asserts, the medical necessity is met for the proposed treatment and is consistent with prevailing standards of professional practice, published guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below; this answer is in keeping with New York State instruction for this medical necessity review including the appropriate application of the NY State NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool that requires the patient in this scenario default to the higher level of care.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The proposed inpatient treatment is medically necessary and clinically appropriate in this case scenario. The patient's clinical features and treatment dimensions did warrant inpatient level detoxification services through discharge and did necessitate the 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 though the patient did discharge against medical advice. 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 in the answer to question 2. 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.