Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Treatment:  Continued inpatient admission
The proposed treatment, continued inpatient admission was medically necessary for this patient.

The continued treatment of this patient's substance use disorders 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 with IV administration on a daily continuous basis; and use of other substances of abuse including cannabis and cocaine that did warrant 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.  Moreover, the patient's social environment was not conducive to detoxification, and the patient struggled initially with withdrawal symptoms and had persistent symptoms of anxiety during the time interval under review 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 continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of PRN medications while receiving evidence-based treatments and withdrawal management.  The patient's history of substance abuse (frequency and quantity), 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.  The patient was at high risk for treatment failure if the detoxification and withdrawal management were to be attempted at a lower level of care, and he needed the support and motivational enhancement therapy to facilitate his step down for residential rehabilitation treatment.  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 3.0 Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission was medically necessary and clinically appropriate in this case scenario and is, therefore, a covered service.  Indeed, the patient's clinical features and treatment dimensions did warrant an admission for 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.  Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition with sober housing. 

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 of continued inpatient admission is not excluded under the plan and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.