Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Continued inpatient admission

The continued inpatient admission was medically necessary for this patient.
The requested benefit of the continued inpatient admission 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 opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of 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 safely or effectively proceeded at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with moderately severe withdrawal symptoms that persisted requiring withdrawal management, and the patient's social environment was not conducive to detoxification. Again, the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses. Thus, the continued detoxification treatment of this patient's substance use disorder 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 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 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 Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission is medically necessary in this case scenario, and therefore should be covered in this case scenario. The health plan contends that the patient could have been treated at inpatient rehabilitation level of care. However, the patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, 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 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, referenced below.