Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented seeking inpatient substance abuse services. He was placed on a five-day methadone and Librium protocol. He is unemployed and undomiciled and was unable to remain clean on his own. He was lacking the coping skills needed to remain sober and he needed help to identify triggers and stressors. He reportedly had abdominal pain, joint pain and nausea, which were getting worse over time. If those medications were not provided, then he would continue to experience additional withdrawal symptoms and the goal was for the client to complete the detoxification and stepdown to rehabilitation services. He did leave from this facility against medical advice and did not take any aftercare recommendations.
Test results indicate that his alcohol level was 0. His toxicology screen showed that opioids and cocaine were positive. He reported that he was drinking one pint of vodka daily and his last day of use was on the day of admission for alcohol, heroin, and cocaine. He was sniffing heroin and smoking crack cocaine. Per the provided documents, he was not on any medication-assisted treatment at the time of admission. He was on disability for mental health conditions. His coexisting psychiatric disorder was bipolar disorder. He was not previously treated for his mental illness. He reported nausea, abdominal pain, and feeling tired. His past medical history is significant for asthma and arthritis. His exam revealed a thin build and the patient was irritable and guarded.
He has a diagnosis of alcohol dependence, uncomplicated alcohol withdrawal, uncomplicated opioid dependence with intoxication, and uncomplicated cocaine dependence with intoxication. Per Clinical Institute Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Scale (COWS) low scores, there were no major withdrawal symptoms at the time of admission.  Vital signs on admission indicated that his blood pressure and heart rate were within normal limits.
On his third day of detoxification protocol, the patient presented to the nursing station and requested to be discharged. He gathered his belongings and signed out against medical advice (AMA).
The patient came to this facility self-referred. He reported that he had never been in treatment. He reported that he was tired of life and he was abusing cocaine since age 16 and unable to stop using. He had negative consequences including homelessness. He does not stay in a shelter, but on the streets. He reported that he does not like people; however, he was friendly and nice during his stay. He was not sure what to do after detox, but he was encouraged to stay through rehabilitation and find a long-term treatment.
Several other assessments regarding his medical conditions, purified protein derivative (PPD) status and others were noted. Detoxification protocol from heroin/opioid documents were noted. He was started on methadone treatment on admission and was continued on this. He also was started on alcohol dependency and Librium tapering protocols. He was also provided other medications including vitamins. No psychiatric medication was noted for his psychiatric conditions.
Nursing documentation indicated that he was medicated as per protocol and he was interacting well with peers and no distress was noted. His withdrawal was closely monitored, and he was alert and oriented. He stated that his pain was subsiding, he was spending time in the smoke room and no distress was noted or reported.
Documentation of the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) form indicated that his most potential substance to cause harm was alcohol. It was noted that he met criteria for tolerance and withdrawal. The health plan's determination is upheld.
The patient was admitted due to alcohol, opioid, and cocaine use disorders. On admission, his blood alcohol level was 0 and he did not show any major withdrawal symptoms as documented with his CIWA score. He also was using opioids (sniffing heroin) and smoking crack cocaine. His admission toxicology testing was positive for opioid and cocaine. He was started on a Librium taper down protocol for alcohol withdrawal and also was started on methadone treatment for opioid withdrawal. Both of his withdrawal scales were showing low scores. Per the nursing notes, he was calm, compliant and was able to interact with peers during the sessions. The patient requested to be discharged against medical advice and left the premises. At the time of admission and during the stay, his vital signs were within normal limits and the withdrawal scale scores were very low indicating very mild withdrawal symptoms. He did not have any medical or psychiatric complications and he was not experiencing any high risk factors for complex withdrawal. Based upon Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)-3.0 criteria for substance abuse services, he did not require 24-hour medical monitoring and frequent monitoring of vital signs provided on inpatient detox unit, and his substance use care could have been safely provided in a less restrictive setting.
On admission, his blood alcohol level was 0 and he did not show any major withdrawal symptoms as documented with his CIWA score. His admission toxicology testing was positive for opioid and cocaine. His withdrawal scales were showing low scores. During his stay, he was calm, compliant and was able to interact with peers during the sessions. He requested to be discharged against medical advice and left the premises.
Since there was no active withdrawal, as documented with low withdrawal scores, there was no medical reason for him to be treated at this level of treatment.