Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction-Fentanyl/heroine and cocaine abuse
Treatment: Inpatient level of care
The health plan denied the inpatient level of care as not medically necessary for this patient. 
The reviewer has overturned in whole the health plan's determination.

The patient was admitted to acute inpatient level services for detoxification and withdrawal management of opioid (heroin/Fentanyl) and stimulant (cocaine) use disorders. The patient was using up to two bundles of heroin/Fentanyl daily with intranasal administration, and up to ten bags of cocaine with snorting. The patient had experienced severe opioid withdrawal in the past when attempting to cut down and he had received detoxification and rehabilitation services in the past with relapses. He presented with mild withdrawal at the time of admission with chills, nausea, abdominal cramp, tearing and rhinorrhea, as well as anxiety, irritability, and restlessness with a Clinical Opiate Withdrawal Scale (COWS) scale score of 11 that increased to 14 on the day of admission. The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone taper together with vitamin and nicotine replacement therapy, and medical monitoring. He was treated with gabapentin and trazodone on an as needed (prn) basis and comfort medications including baclofen. The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. The patient was discharged with recommendations for clinically appropriate aftercare. He declined a formal referral for rehabilitation treatment, but indicated he planned to enter treatment at a treatment facility near his home.

The requested health service/treatment with inpatient hospital admission and with Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services was medically necessary for this patient.
Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer and determination is consistent with New York State instruction concerning medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria and Guidelines.
The proposed 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 adult inpatient treatment of this patient's substance-related disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, heroin, Fentanyl, and cocaine. Withdraw symptoms were managed with tapering dosages of methadone requiring monitoring, as well as the availability of comfort medications and nicotine replacement and vitamin replacement. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to 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, 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 at a lower level of care. And the New York State OASAS LOCADTR 3 Criteria were met in this case.