Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse disorder
Treatment: Inpatient detoxification
The insurer denied the inpatient detoxification.
The denial is overturned. 

The patient is a female requesting detoxification treatment and admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin) class substance, as well as the past use of cannabis and stimulant (crack cocaine) class drugs of abuse. The patient had been using up to 20 bags of heroin with intravenous (IV) administration. She had a history of prior detoxification and substance use disorder treatments with up to four treatment episodes with relapse. She rapidly progressed to using two bundles of heroin daily. She had severe withdrawal symptoms when attempting to cut down and had developed an abscess at an injection site requiring antibiotic treatment. Her self-referral for treatment was prompted by multiple stressors including occupational, primary support, social environment and other psychosocial domains.

The patient has a history of psychiatric disorder with unspecified anxiety and depressive disorders. She denied psychiatric hospitalization or suicidal or self-harming behavior. She had an inadvertent drug overdose requiring emergency medical services.

The patient presented without acute co-morbid general medical issues. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history. The patient is an everyday smoker and tobacco dependent at one pack per day. She has a history of lower back pain that contributes to her use of opioids.

The patient is single and unemployed with housing, living with her father. She did not report trauma or abuse history, or legal issues. She reported a family history of substance use disorder reflecting genetic predisposition. She reported having family support from parents and siblings but was without sober supports and had stopped attending recovery groups.

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. She was generally motivated for treatment but was only contemplative at best. She was described as polite and cooperative with a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and aches due to the onset of opioid withdrawal. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment or other severe symptoms as noted. The patient denied suicidal or homicidal ideation and did not have perceptual disturbance. Insight was limited with impaired judgment and poor control of impulses. Her onset of withdrawal symptoms included anxiety, restlessness, agitation, tremor, nausea and diarrhea and abdominal cramps, sweats, chills and body/bone aches.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with use of Suboxone when appropriate, and clonidine as needed, and as needed (PRN) medications for comfort, as well as nicotine replacement therapy and smoking cessation education. The program provided for case management with referral to sober housing 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 counseling and milieu activities including peer support and education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal during her brief stay. The patient was maintained on a psychotropic medication regimen of Lexapro, Neurontin and Seroquel together with PRN medications for agitation and anxiety (Vistaril and Thorazine). Nutritional supports and fluid replacement were provided and continued use of antibiotic therapy.

The patient initially was hampered by withdrawal symptoms and the desire to leave treatment on the first two days of detoxification. The patient more actively engaged with detoxification treatment and therapeutic activities within the treatment milieu; she was cooperative and feeling better with diminishing withdrawal symptoms. Withdrawal symptoms remained mild, but persisted with aches, pain, anxiety and insomnia requiring prn medications, as noted, and monitoring. Case management was working on a safe and clinically appropriate discharge plan and disposition.  The patient was discharged with immediate transfer to substance use disorder rehabilitation treatment and plans for continued medication assisted treatment with Suboxone and involvement in recovery groups.

Yes, the proposed treatment, inpatient detoxification, was 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 in large quantities with IV administration that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; 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.  Moreover, the patient had significant and 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 including a recent drug overdose.

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 PRN medications. The patient's history of substance abuse (frequency and quantity) including a history of drug overdose and presentation with co-occurring anxiety and mood disorders and 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, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, 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 inpatient detoxification was medically necessary and clinically appropriate in this case scenario and is therefore a covered service in this case. The patient's clinical features and treatment dimensions did warrant inpatient level detoxification services thru 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, and the continued treatment for the mood and anxiety disorders. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment with formal substance use disorder treatment with a safe and clinically appropriate disposition. 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 the application of ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.