Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient substance abuse treatment.
The insurer denied the Inpatient substance abuse treatment.
The denial is overturned. 

The patient is a male. He presented to an emergency department requesting substance use disorder treatment and who was admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin), alcohol and stimulant (crack cocaine) class substances, as well as intermittent use of cannabis class substances of abuse.

The patient had been using up to two and one-half pints of vodka and five 24-ounce beers per day together with up to $100 worth of crack cocaine daily, and the patient was receiving medication assisted treatment with Suboxone while using up to five bags of heroin with intranasal administration (snorting). The urine drug screen was positive for cocaine. 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 being 36 months. His self-referral for treatment was prompted by multiple stressors including occupational, primary support, legal, social environment and housing domains.

The patient has a history of psychiatric disorder best characterized as schizophrenia managed with assertive community treatment (ACT) and a long-acting injectable antipsychotic medication, Invega Sustenna at 156 mg (milligrams) per month. The patient has a history of multiple psychiatric hospitalizations and non-compliance with his mental health treatment.

The patient presented without acute co-morbid general medical issues. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history, as noted. The patient is an every day smoker and tobacco dependent. He has chronic medical conditions including diabetes mellitus and asthma.

The patient is single, unemployed and homeless. He did not report legal history with an open court date. He had limited social supports.

The patient's 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 and sleep disturbance associated with alcohol withdrawal. 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. 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, nausea and diarrhea, rhinorrhea, sweats, rhinorrhea and yawning, and aches.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Librium continued use of Suboxone, and prn (as needed) 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. Withdrawal symptoms diminished and vital signs remained normal. The patient left the treatment program with an AMA (against medical advice) discharge and recommendations for continued mental health and substance use disorder treatment including involvement with self-help recovery groups.

Yes, the Inpatient substance abuse treatment was medically necessary for this patient.

The requested Inpatient 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 and cocaine together with a large quantity of alcohol on a daily continuous basis 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 admission and continued adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn (as needed) medications. The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment, co-occurring psychiatric disorder 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 detoxification and withdrawal management were to be attempted at a lower level of care. The case was also complicated by a severe and persistent co-occurring psychiatric disorder, as noted in the clinical summary. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) 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 OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of inpatient substance use disorder treatment is medically necessary and clinically appropriate in this case scenario, and should therefore be covered in this case scenario. Indeed, the patient's clinical features and treatment dimensions did warrant inpatient level detoxification and other medical 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 efforts to achieve 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 in the answer to question 2. 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 (American Society of Addiction Medicine) Criteria and the New York State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria, referenced below.