Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid dependence
Treatment: Continued inpatient admission 
The proposed treatment, 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 large quantities of opioid/heroin with recent progression to IV administration/injection of the drug that did warrant inpatient level detoxification and withdrawal management and monitoring; detoxification, as indicated, 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 with continued treatment going forward.  Moreover, the patient presented with moderately severe withdrawal symptoms that worsened during her stay, and, the patient's social environment was not conducive to detoxification, and 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), and the presence of severe symptoms of anxiety and persistent withdrawal symptoms 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 continued 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, the continued stay is consistent with New York State instruction for medical necessity reviews including 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 is medically necessary in this case scenario, and is therefore a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and treatment for the co-occurring anxiety disorder. 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 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 appropriate application of New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.