Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Six Units Inpatient Substance Abuse
The insurer denied the Six Units Inpatient Substance Abuse
The denial is overturned. 

The case involves a male patient who presented to an emergency department requesting detoxification and substance use disorder treatment, and who was screened and admitted to acute inpatient level care beginning in order to address substance use disorder with opioid (heroin), alcohol, cannabis and stimulant (cocaine) class substances. 

The patient had been using up to one pint of liquor and 12 beers per day together with up to one gram of cocaine daily, and up to twelve bags or two bundles of heroin with intranasal administration (snorting), as well as one marijuana blunt per day. He denied history of withdrawal seizures or delirium tremens, but reported blackouts.

This patient had a history of prior detoxification and rehabilitation treatments with treatment episodes and relapses with his longest period of sobriety at 36 months. His self-referral for treatment was prompted by multiple stressors including occupational, primary support, social environment and housing domains.

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 anxiety related to withdrawal symptoms and okay sleep. Speech was clear with organized thoughts that were free of delusions. There was no evidence for mania, acute symptoms of psychosis or severe cognitive impairment (delirium or dementia). 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 withdrawal symptoms included anxiety, irritability, pain, and aches with a Clinical Opiate Withdrawal Scale (COWS) score of six (mild) and elevated blood pressure.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with five-day tapering dosages of methadone and valium, and as needed (PRN) medications for comfort, as well as vitamin and nicotine 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 the brief detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and, involvement with milieu activities including peer support and sessions to motivate the patient to proceed to rehabilitation treatment. The patient was placed on a pain management protocol. Withdrawal symptoms persisted, but diminished with continued aches and pain at a seven out of ten (7/10) day one, mental confusion and persistent aches, pain and elevated blood pressure on days two and three, with improvement noted on day four. The patient completed the detoxification protocol and was discharged with immediate step down for rehabilitation treatment and with recommendations for continued involvement with self-help recovery groups, and consideration of medication assisted treatment and smoking cessation.

Yes, the proposed treatment, continued inpatient substance use disorder treatment with detoxification and withdrawal management was medically necessary for this patient.
The patient in this case was using heroin and cocaine together with large quantity of alcohol on a daily continuous basis; and use of other substances of abuse that did warrant continued 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 and during the time interval under review.  Moreover, the patient had persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification, and the patient struggled with symptoms of anxiety in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the continued 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 as needed (PRN) medications. The patient's history of substance use (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 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, American Society of Addiction Medicine (ASAM) Criteria and Level of Care Utilization System (LOCUS) Guidelines, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Tool that requires the patient in this scenario default to the higher level of care.