Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient substance abuse admission
The insurer denied the inpatient substance abuse admission
The denial is overturned.

The patient is an adult male who presented to an emergency department
requesting detoxification and substance use disorder treatment. He was screened
and admitted to acute inpatient level care in order to address substance use disorders with opioid, alcohol, cannabis and stimulant class substances. The patient was concerned for his health and stressed by his responsibilities at home, as well as several pending legal issues.

The patient has a history of psychiatric disorder, schizophrenia, and multiple
psychiatric hospitalizations in the past. He was not currently in treatment for his
mental disorder.

The patient presented without acute co-morbid general medical issues. Laboratory
assessments, EKG (electrocardiogram) and Chest X-Ray were unremarkable or
normal with a positive drug screen consistent with history. The patient has chronic
medical conditions including GERD (gastroesophageal reflux disease), gastritis and
arthritis treated with pantoprazole and analgesics.

The patient was admitted to detoxification treatment with a comprehensive
detoxification protocol with five-day tapering dosages of Methadone, and prn (as
needed) medications for comfort. The program provided for case management and
access to rehabilitation treatment that included comprehensive evidence-based
treatments.

During the brief detoxification, the patient did not readily engage in counseling
sessions focusing on education about the disease model of addiction, and,
involvement with milieu activities including peer support and sessions to motivate
the patient to proceed to rehabilitation treatment. His stage of change was
precontemplative and he tended to isolate indicating that he was meditating.
Withdrawal symptoms persisted and increased to a COWS (clinical opiate withdrawal scale) scale score of 9, and subsequently diminished with continued with improvement noted with discharge planning. The patient completed the detoxification protocol and was discharged with immediate step down for rehabilitation treatment and with plans for medication assisted treatment and recommendations for involvement with self-help recovery groups, and consideration of treatment for his co-occurring mental disorders and general medical conditions. At the time of his discharge, he remained with poor
insight and in a pre-contemplative or contemplative stage of change.

Yes, the inpatient substance abuse admission was medically necessary.

The insurer states that the patient did not meet New York State OASAS (New York
Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and
drug treatment referral) 3.0 Criteria, and was medically stable and had mild
withdrawal symptoms at the time of presentation with normal vital signs, as well as
not having psychiatric symptoms that required inpatient level care. However, the
denial did not take into account the treatment dimensions in a patient who was
using heroin up to the date of presentation, had frequent relapses despite treatment
and little history of abstinence in the context of comorbidity with deficient coping
skills and a lack of insight and motivation, as well as a severe and persistent mental
disorder impacting the patient's ability to sustain a recovery effort. Thus, the
treatment facility notes in the appeal that the patient did meet LOCADTR (level of
care for alcohol and drug treatment referral) 3.0 Criteria and published guidelines
from the APA (American Psychiatric Association) and SAMHSA (Substance Abuse
and Mental Health Services Administration) as well as having clinical features and
treatment dimensions that required inpatient level structure and monitoring with
treatment and withdrawal management. Moreover, the history of relapses and
comorbidities complicated the case, as well as the lack of insight and poor impulse
control and impaired judgment associated with poly-substance use and comorbid
schizophrenia that was generally untreated in the context of substance use. Thus,
the appeal indicated that the requested inpatient level treatment was appropriate
with regard to structure, setting, intensity of treatment and length of treatment.

In this case, New York State LOCADTR (level of care for alcohol and drug
treatment referral) 3.0 Criteria are met for inpatient level treatment that was
appropriate with regard to structure, setting, intensity of treatment and length of
treatment. The patient in this case was using heroin and cocaine together with
large quantity of alcohol on a daily continuous basis; and use of other substances of
abuse that did warrant 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 and during the time interval
under review. Moreover, the patient had persistent withdrawal symptoms, and, the
patient's social environment was not conducive to detoxification, and the patient
struggled with symptoms of anxiety in the context of limited insight, impaired
judgment and poor control of impulses.

The patient's history of substance use (frequency and quantity) together with the
high drug-use social environment, 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, inpatient substance abuse admission was medically necessary in this
case and is consistent with prevailing standards of professional practice, published
practice guidelines, ASAM (American Society of Addiction Medicine) Criteria and
LOCUS (Level of Care Utilization System)
Guidelines, and the scientific literature, referenced below, and, New York State
instruction for medical necessity reviews including the appropriate application of the
NY (New York) State OASAS (New York Office of Addiction Services and Supports)
LOCADTR (level of care for alcohol and drug treatment referral) Tool that requires
the patient in this scenario default to the higher level of care with inpatient level
treatment.