Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presented to the emergency department requesting detoxification/rehabilitation and was medically screened and admitted to inpatient level services for detoxification of opioids, cocaine, Xanax and alcohol use; he had been using up to 14 bags of heroin with intravenous (IV) administration together with up to one gram of cocaine, as well as use of 4 milligrams (mg) of Xanax and alcohol. His substance use disorder had its onset in adolescence with progression of the disease over a ten year time frame with severe opioid, stimulant sedative-hypnotic-anxiolytic and alcohol class substance use disorders. The patient reported a past history of withdrawal seizures two years prior to admission but had no history of delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 2 and Clinical Opiate Withdrawal Scale (COWS) scale score of 6 reflecting minimal withdrawal symptoms and complaints of loose stool, headache and chills.

The patient was admitted and placed on a detoxification regimen with comfort medications, as well as vitamin replacement therapy. He was prescribed quetiapine, sertraline and gabapentin to address his mental health conditions. The detoxification was uncomplicated with regard to withdrawal management. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and the patient was discharged with referral for clinically appropriate aftercare and rehabilitation services.

The health plan's determination is upheld.

The requested inpatient substance abuse treatment and withdrawal management could have been safely and effectively provided at a lower level of care status. The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe and the patient had received detoxification treatment 7-8 days prior to his presentation accounting for minimal or light withdrawal symptoms, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of recent complicated withdrawal from drugs or alcohol despite the history of withdrawal seizures two years prior to presentation. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria, scientific literature, referenced below. Additionally, medical necessity for the requested inpatient detoxification and other medical services is not met in keeping with NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.