Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient Detoxification Treatment.

The insurer denied the Inpatient Detoxification Treatment.  The denial is overturned.

The patient is an adult male who presented requesting detoxification treatment. He was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid, alcohol, stimulant (designer stimulant and cocaine) and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using one pint of alcohol, ten to 20 bags of heroin and $100 of crack cocaine daily, as well as benzodiazepines and designer stimulant. He has no history of withdrawal seizures or delirium tremens. He had a history of at least ten prior detoxifications for substance use disorder with no report of rehabilitation treatment or significant outpatient follow up or aftercare.

The patient has a history of psychiatric disorder with unspecified post-traumatic stress disorder (PTSD) and depressive disorder without current treatments. He had no history of psychiatric hospitalization or suicidal behavior and was not taking psychotropic medications.

Laboratory assessments were unremarkable or normal other than elevated liver functions with a positive drug screen consistent with history, as well as positivity for benzodiazepine and cocaine. The patient has a history of peripheral vascular disease and past treatment with anticoagulants, a gunshot wound to the head, and a positive purified protein derivative (PPD); he uses a cane to ambulate. The patient was tobacco dependent.

The patient's withdrawal symptoms included body aches, chills, abdominal cramping, nausea, sweats, and tremor, scoring a 15 on the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale and a 14 on the Clinical Opiate Withdrawal Scale (COWS).

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of methadone and Librium. Withdrawal symptoms remained mild and diminished with persistent irritability. The patient did not complete the detoxification treatment and was discharged against medical advice with referrals for clinically appropriate aftercare, which the patient declined.

The denial was on the basis of the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient had no symptoms that warranted 24-hour monitoring suggesting outpatient level care as clinically appropriate.

The appeal was on the basis of the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient needed the structure of an inpatient setting in order to be effectively managed, and that the patient was not clinically stable with reference to the Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scoring and clinical features warranting the inpatient level of care.
The issue under review is inpatient detoxification and withdrawal management.

The proposed treatment was medically necessary.

The requested inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin, together with alcohol and stimulants and other substances of abuse on a daily continuous basis that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; detoxification, as necessary. Moreover, the patient had a positive drug screen that included opioids and amphetamine and benzodiazepines, as well as cocaine. He had moderate and persistent withdrawal symptoms, and the patient's social environment was not conducive to detoxification.

Therefore, medical necessity is met in this case.