Appeal type: Medical necessity
Decision: Overturned

The patient is a female who was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of opioid (heroin) and cannabis use disorder.  She had relapsed while participating in outpatient level substance use disorder treatment with medication assisted treatment with Suboxone.  She was using up to 10 bags of heroin with intranasal administration on a daily basis together with marijuana.  The patient presented with opioid withdrawal at the time of admission with a Clinical Opiate Withdrawal Scale (COWS) scale score of 8.  She reported severe withdrawal symptoms in the past when attempting to stop or curtail his use of the drugs.  She had participated in past detoxification treatments for the substance-related disorders with at least three treatment episodes with the last occurring two years prior to presentation with subsequent involvement in medication assisted treatment, as noted.  The patient's substance use started twenty-five years previously with recurrences and escalating use and progression of the disease.

The patient was admitted to inpatient level care and placed on a detoxification regimen with Suboxone, vitamin and nicotine replacement therapy, and medical monitoring.  Withdrawal symptoms initially included tremor, sweats, chills, aches, nausea, anxiety, irritability and restlessness.  Following her first day of treatment, the patient was feeling better and had participated actively in counseling and educational sessions, as her withdrawal symptoms diminished quickly.  She did continue with detoxification treatment and did benefit from active treatment with the educational and counseling sessions during the remaining inpatient hospital stay.  The patient was discharged with immediate transfer to outpatient substance use treatment with continued medication assisted treatment with Suboxone and recommendations for clinically appropriate aftercare, as well as recommendation for involvement in 12-step recovery meetings with peer support.

The health plan's determination is overturned. 

The inpatient services and detoxification treatment and withdrawal management for severe substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care.  The treatment of this patient's substance use disorders did warrant the structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with a relapse, while participating in outpatient substance use disorder treatment.  Withdrawal symptoms were managed with resumption of Suboxone requiring monitoring, and vitamin and nicotine replacement therapy, and as needed (prn) medications, as well as the availability of comfort medications to address anxiety, agitation, insomnia and pain.  Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition and return to outpatient rehabilitation substance use disorder treatment.

Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments that were considered medically necessary in this case, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted/initiated at a lower level of care.