Appeal type: Medical necessity
Decision: Overturned

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

The patient is a adult male. He presented to the emergency department requesting detoxification treatment and was admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin) and stimulant (cocaine) class substances. The patient had been using up to 10 bags of heroin with IV (intravenous) administration as well as four bags of cocaine daily. His use of heroin had escalated and he was unable to cut down due to severe withdrawal symptoms.

The patient had a history of prior detoxification and substance use disorder rehabilitation treatments with relapses. His self-referral for treatment was prompted by multiple stressors including occupational, primary support, housing, social environment and other psychosocial domains, and he had somatic complaints that included abdominal cramps and nausea with withdrawal symptoms from heroin including anxiety, irritability, body aches, joint pain, gastrointestinal upset (nausea and diarrhea), rhinorrhea and tremors.

The patient has no history of a psychiatric disorder and denied past history of suicidal or self-harming behaviors.

The patient presented without acute co-morbid general medical issues. He had a history of asthma with a rescue inhaler and stage 3 chronic kidney disease. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history.

The patient is married and unemployed with family support that included living with his spouse. There were no current legal issues but the patient has a history of incarceration and legal arrests. He denied trauma history or family history of substance use or mental disorder.

The patient's evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with a full range of affect. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses. His onset of withdrawal symptoms had initially included anxiety, irritability, agitation with tremors, sweats, gastrointestinal upset and body/muscle aches.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone, and prn (as needed) medications for comfort including clonidine, as well as vitamin replacement therapy. 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 his brief stay.

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of methadone. Withdrawal symptoms remained mild and resolved after the first two days of treatment. The patient completed the detoxification treatment and accepted referral for rehabilitation treatment. There were no complications during his inpatient stay. 

Yes, the inpatient substance abuse treatment 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, together with cocaine with IV (intravenous) administration of heroin in large quantities on a daily continuous basis that did warrant the admission for 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 a positive drug screen that was consistent with history. He had mild and persistent withdrawal symptoms through day 2. 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 prn (as needed) medications and other medical services. 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 detoxification and withdrawal management were to have been 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 (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, and with New York State instruction for medical necessity reviews including the appropriate application of the NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care determination) Tool that requires the patient in this scenario default to the higher level of care.