Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid dependence
Treatment: Continued inpatient admission 
The proposed continued inpatient admission was medically necessary for this patient.

The detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level detoxification setting and monitoring. The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment and negative influence of peers and severe psychosocial stressors that included legal issues and the patient's functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management; the patient was at high risk for treatment failure if detoxification and withdrawal management were to be attempted or continued at a lower level of care. The patient had deficient coping skills, significant withdrawal symptoms at the time of admission and persistent withdrawal symptoms while undergoing detoxification treatment, and, the patient clearly could not have completed or sustained a detoxification treatment episode at a lower level of care, especially in view of limited past treatment history and his relapse while receiving medication assisted treatment with Suboxone. 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 with New York State instruction for medical necessity reviews including the application of the NY OASAS LOCADTR 3.0 Tool (referenced below) that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission for detoxification services and withdrawal management and other supportive services is medically necessary and is therefore a covered service in this case scenario. The inpatient admission and treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. The comorbid substance use disorders complicated this case, as the patient was using cocaine together with large quantities of heroin on a daily basis with IV administration, and while in outpatient substance use disorder treatment that included medication assisted treatment with Suboxone. The use of multiple substances of abuse is pertinent to the selection and necessity of an inpatient treatment setting in this case scenario, as well as consideration of the patient's the lack of sober supports and ongoing psychosocial stressors including an  extensive legal history and violations of his parole/probationary status, and lack of coping skills. Thus, the requested benefit of continued inpatient admission for detoxification treatment and other related services thru discharge should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the application of New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.