Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient substance abuse admission.
The insurer denied the inpatient substance abuse admission.
The denial is upheld.

The patient is an adult male, who was admitted to inpatient level services for detoxification treatment, stabilization and withdrawal management of
opioid use disorder, sedative-hypnotic-anxiolytic use disorder, stimulant use
disorder and cannabis use disorder.

At the time of admission, the patient's CIWA (Clinical Institute Withdrawal
Assessment) scale score was at 10/67 and the COWS (clinical opiate withdrawal scale) scale score was at 7/48 reflecting mild withdrawal symptoms.

There were no acute psychiatric or acute general medical issues in this case. He reported no prior psychiatric hospitalization, suicidal behavior or self-harming behavior.

The patient's mental status examination on admission was free of severe
symptoms. Insight and judgment were considered fair though impaired due to the substance use disorders. The patient was deemed to be motivated to enter
detoxification treatment. He denied suicidal ideation or aggressive behavior.
Speech was clear with linear and logical thought. Mood was euthymic with anxiety and insomnia. There was no evidence of mania, thought disorder, psychosis, perceptual disturbance or cognitive impairment.

The patient was admitted and placed on a detoxification regimen. Withdrawal
symptoms were mild, and were not measured throughout the inpatient stay. The
detoxification was uncomplicated with regard to withdrawal management. He was
sleeping and eating without distress. He was taking care of his daily needs without
assistance. However, he was characterized as demanding and belligerent with
hostility, anger, tension and excitability. He had the opportunity to participate in
counseling and education, as the program would allow, as well as recovery groups
and focus on relapse prevention and better coping.

The case manager arranged for the patient to transition for rehabilitation treatment
and aftercare including consideration of medication assisted treatment with
Suboxone which was started during his detoxification treatment, as he refused
methadone on day three of his stay. He was discharged, continuing
with rehabilitation treatment until with subsequent recommendations for
clinically appropriate aftercare to include medication assisted treatment and
involvement in recovery groups with peer support.

The insurer denied coverage for the stay, indicating that New York State OASAS
(New York Office of Addiction Services and Supports) LOCADTR (level of care for
alcohol and drug treatment referral) Criteria were not met and that the patient did
not need methadone or a Valium taper. There were no general medical or
psychiatric issues in this case, or need for withdrawal management or induction
with Suboxone in an acute inpatient setting.

No, the Inpatient substance abuse admission was not medically necessary.

The patient's withdrawal symptoms were not reported to be severe and were mild
as assessed with the COWS (clinical opiate withdrawal scale) scale of opioid
withdrawal and the CIWA (clinical institute withdrawal assessment) scale of
benzodiazepine withdrawal. A such, the patient's clinical presentation did not
warrant the admission and continued inpatient level treatment or 24-hour
monitoring. In addition, the patient did not present with severe psychosocial
stressors or psychiatric disturbances that would have posed a problem if
detoxification treatment was provided in a less restrictive treatment setting.

The patient's presentation and clinical features did not warrant the intensity of
inpatient level services or inpatient level structure or 24-hour monitoring and could
have been safely and effectively provided at a lower level of care.