Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse/addiction
Treatment:  Substance Abuse:Inpatient

The patient with a history of opiate and cocaine use disorder was admitted to an inpatient detox unit.  Urine was positive for opiates, cocaine, and methadone.  Vital signs were all in normal range.  Patient endorsed using heroin and cocaine daily; 7-8 bags/day and $80/day, respectively.  Patient last used, about 1/2 daily amount.  Patient did not endorse using methadone as a drug of abuse and staff did not document any discussion of why urine was positive for methadone.  To the triaging nurse, the patient complained of nausea, sweats, abdominal pain, teary eyes, joint pain and rhinorrhea.  Later to the physician the patient complained additionally of trouble sleeping, anxiety, yawning, tremors, irritability, and headache.  On physical exam the patient was tremulous, anxious and had moist eyes, flushed face and dilated pupils.  The initial Clinical Opiate Withdrawal Scale (COWS) score was 14.  The facility completed an admission Level of Care for Alcohol and Drug Treatment Referral (LOCADTR).  In it staff indicated the patient lacked support for early recovery.  The template instructions indicate that if this box is checked it should result in medically supervised withdrawal, and if the patient does have supports, it should result in outpatient referral.  Staff also indicated the patient is at risk for moderate withdrawal.  The patient reported a history of 9 previous detox stays and one previous rehab stay.  Patient denied any psychiatric history, including no previous diagnosis, treatment, suicidality or hallucinations.  The patient has sickle cell trait/anemia but no other chronic conditions and is not on any home medications.
Patient reported living stably with a family member and being satisfied with her current housing.  Patient was admitted to the detox unit and placed on a five day methadone taper.  The patient was educated on medication assisted treatment (MAT) by the Credentialed Alcoholism and Substance Abuse Counselor (CASAC) but declined to learn more.  There are no repeated COWS assessments.  Patient had agreed to a plan for rehab but then changed her mind and elected to go home.  Patient was given a Narcan kit at discharge.  The health plan's determination of medical necessity is upheld in whole.  The patient's presentation is consistent with clinically mild opiate withdrawal.  Nothing on  presentation stands out as uniquely related to a crash from cocaine, but some of the general complaints could be related to that as well.  Opiate and cocaine withdrawal are not medically dangerous on their own and are usually appropriate for outpatient management.  Inpatient detox for opiates or cocaine is recommended only in special circumstances such as having epilepsy, an unstable heart condition, an unstable psychiatric condition, etc.  The patient had no unstable medical conditions, no psychiatric history, and was stably housed with family and was receiving public assistance.  There is no documentation in this chart that substantiates the patient has a lack of supports.  This reviewer completed a LOCADTR using the information documented in the medical record, and it resulted in a recommendation for outpatient detox with medication assistance.  This result is also consistent with medical opinion that inpatient detox was not medically necessary.