Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of heroin and cocaine use disorders who presented to the hospital requesting medical detoxification from the substances. He reported use of heroin on the day prior to admission. He reported use of heroin since age 27. He denied having medication assisted treatment in the past. He reported some abstinence in the past for an unspecified length of time. He described using 5-10 bags of heroin daily. He denied any history of withdrawal seizures, blackouts, delirium tremens. There was no documented history of overdoses. He was complaining on admission of nausea, fatigue, insomnia, tremors, malaise, anxiety, nervousness, loss of appetite, chills, muscle cramps, restlessness, joint pains, irritability, and sweats. Patient denied any history of a suicide attempt and denied any suicidal or homicidal ideation at the time of admission. The patient also denied feeling down, depressed or hopeless.

The patient was admitted to the hospital and a methadone taper was started. The patient was also continued on home medications. The patient tolerated treatment well and completed detoxification and was discharged. The patient did not at any point exhibit unstable medical or psychiatric symptoms. The patient did not have intractable nausea or vomiting. There were no significant electrolyte abnormalities or other indications of manifestations of severe opioid withdrawal. The health plan's determination is upheld. 

The inpatient stay was not medically necessary for this patient.
The patient did not have a life-threatening medical condition or severe psychiatric crisis that required immediate hospitalization. Opioids were the primary substance with the potential for harm to self or others. The patient clearly met criteria for an opioid use disorder. The patient did not have an opioid use disorder that was in remission. The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting for substance use disorder treatment to be effective. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting. The patient was not documented as using substances and hazardous situations that were imminently dangerous to self or others. The patient did have interpersonal deficits as evidenced by difficulty maintaining stable employment and maintaining stable relationships. There is no documentation that the patient exhibited predatory behavior. The patient did have strong cravings or urges, but it was not clearly documented that this would require stabilization in an inpatient setting. It was not clearly documented that the person had a problem managing triggers for substance use and their environment.

Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria, the appropriate Level of Care is: Rehabilitative Services in a Residential Setting.

This patient was admitted for detoxification from opioids. Clinical documentation does not establish that withdrawal from opioids had created a medically unstable situation for the patient. The patient did not have intractable nausea or vomiting, seizures, electrolyte abnormalities consistent with severe withdrawal, or other severe symptoms of opioid withdrawal. Clinical documentation does not establish why the care could not have been delivered at a lower level of service. Clinical documentation does not establish the reason why medication assisted treatment could not have been induced. The patient had no suicidal or homicidal ideation or other psychiatric instability requiring inpatient care. The patient could have been safely and effectively treated at a lower level of care.