Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorders
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male who was admitted to acute inpatient level of care for detoxification and withdrawal management and stabilization in order to address substance use disorders with opioid (heroin), alcohol, and stimulant (cocaine) class substances, as well as intermittent use of sedative-hypnotic-anxiolytic class drugs of abuse. The patient had been using up to four bags of heroin with intravenous (IV) administration while participating in a methadone maintenance treatment program (MMTP) receiving 105 milligrams (mg) of methadone daily. He was using one pint of brandy daily together with intermittent use of six milligrams (mg) of Xanax one to two times per week. He was using $20 worth of crack cocaine daily and was tobacco dependent at 12 pack per day. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatments including MMTP (methadone maintenance treatment program) and exposure to 12-step recovery groups. His self-referral for treatment was prompted by multiple stressors including housing, primary support, social environment and other psychosocial domains.

The patient has a history of psychiatric disorder with unspecified bipolar disorder treated with Depakote. He has a history of psychiatric hospitalization with a clinical course best characterized as severe and persistent mental illness. He denied recent suicidal behavior or overdose.

The patient presented with acute co-morbid general medical issues that included diabetes mellitus and poor dentition, missing most of his teeth. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history.

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 with apprehension, nervousness, tension, irritability, sleep disturbance, and aches due to the onset of opioid and alcohol withdrawal. Clinical opiate withdrawal scale (COWS) and Clinical Insitute Withdrawal Assessment (CIWA) scale scores were at nine reflecting mild to moderate withdrawal symptoms. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a formal 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 included anxiety, irritability, insomnia, agitation, nausea, sweats, chills, tremor and body aches.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Librium and continued use of methadone, and clonidine as needed, and as needed (PRN) medications for comfort, as well as vitamin replacement therapy and use of Depakote for seizure prophylaxis and maintenance treatment of the bipolar mood disorder. He received trazodone to address insomnia. 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 inpatient stay. 

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of Librium. Withdrawal symptoms remained mild, but persisted with aches, pain, anxiety and insomnia requiring prn (as needed) medications and monitoring. The patient completed his detoxification treatment protocol and was immediately transitioned to rehabilitation substance use disorder treatment. 

Yes, the proposed treatment, Inpatient Admission 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 while participating in a methadone program, together with alcohol and crack cocaine on a daily continuous basis with intermittent use of large amounts of Xanax 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 a positive drug screen that included opioids and benzodiazepines, as well as methadone and cocaine. He had mild 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.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the inpatient admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of as needed (PRN) medications. The patient's history of substance abuse (frequency and quantity) 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. Additionally, the patient presented with a history of severe and persistent mental illness, unspecified bipolar disorder. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of the NY (New York) State Office of Addiction Services and Supports (OASAS) Level of Care Determination (LOCADTR) Tool required that the patient in this scenario default to the higher level of care.

The requested benefit of Inpatient Admission was medically necessary and clinically appropriate in this case scenario and is therefore a covered service. 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. 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. 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 American Society of Addiction Medicine (ASAM) Criteria and the New York State Office of Addiction Services and Supports (OASAS) Level of Care Determination (LOCADTR) 3.0 Criteria/Guidelines, referenced below.