Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient Detoxification Treatment
The insurer denied the inpatient detoxification treatment.
The health plan's determination is overturned.

The patient is a male who was self-referred and admitted to acute inpatient level services for detoxification and withdrawal management of Opioid (heroin), stimulant (crack cocaine) and alcohol use disorders. He was drinking two 40 ounce beers daily, using up to five bags of Heroin with intranasal administration and $100 dollars' worth of crack cocaine daily. The patient had experienced severe drug and alcohol withdrawal symptoms in the past and he had a history of blackouts and inadvertent overdoses including two weeks prior to admission. He had received detoxification in the past with relapse and has "no clean time."

The patient has no history of a co-occurring psychiatric disorder and denied psychiatric hospitalization or suicidal and self-harming behaviors.
The patient's physical examination and laboratory assessment were normal or unremarkable except for a positive drug screen consistent with his history. The patient's vital signs remained normal throughout the inpatient stay. His blood alcohol level was zero. The patient was tobacco dependent at one-half pack per day use.
The patient presented with anxiety, insomnia and tremors. He had no severe psychiatric symptoms such as mood disturbance, psychosis, perceptual disorder or cognitive impairment. His Clinical Institute Withdrawal Assessment (CIWA) scale score was 6 and his Clinical Opiate Withdrawal Scale (COWS) scale score was 7 reflecting mild withdrawal symptoms.

The patient was admitted to an acute inpatient level care and placed on a detoxification regimen with a Methadone taper together with vitamin replacement therapy and medical monitoring. He was treated with comfort medications including Benadryl for insomnia.

Following his first day of treatment, the patient began to participate in counseling and educational sessions, as he was feeling better. His mental status examination included persistent symptoms of anxiety with associated symptoms of insomnia. During his inpatient stay, the patient demonstrated no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. The patient completed the detoxification treatment without complications. The patient was discharged with a referral for clinically appropriate aftercare including plans for rehabilitation treatment and a follow up with primary care.

The patient also has severe psychosocial stressors with limited support and functional impairments.

The inpatient services, detoxification treatment and withdrawal management for severe poly-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. Twenty-four-hour monitoring was necessary in view of the severity of the substance use disorders with multiple substances of abuse and the associated psychosocial stressors and impairment of functioning. His withdrawal risk was managed with tapering dosages of Methadone, monitoring and as needed (prn) medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition for appropriate rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with inpatient level services and withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse or remain in treatment if detoxification and treatment were attempted at a lower level of care.