Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction
Treatment: Inpatient Substance Use Detoxification Treatment
The insurer denied Inpatient Substance Use Detoxification Treatment.
The health plan's determination is overturned.

The patient is a male who was evaluated and subsequently admitted to inpatient level services for detoxification and withdrawal management of opioid (heroin) and stimulant (cocaine) class use disorders. The patient was using up to one bundle per day with smoking. He presented with mild withdrawal symptoms at the time of admission with sweats and body aches, as well as anxiety, irritability, and restlessness.

The patient had prior exposure to substance-related treatment with no sustained abstinence. He has no history of a co-occurring psychiatric disorder. He denied psychiatric hospitalization, or suicidal or self-harming behaviors. The patient had been medically screened with drug testing that was consistent with his history and with elevated and labile blood pressures. There were no other acute medical issues and no chronic medical conditions in this case.

The patient was admitted to inpatient level care and placed on a detoxification regimen with buprenorphine together with the availability of comfort medications, and medical monitoring. Following his first day of treatment, the patient began to participate in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better with the use of buprenorphine. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia addressed with quetiapine. He demonstrated no severe symptoms such as mania, psychosis, perceptual disturbance, or severe cognitive impairment. He did continue with detoxification treatment briefly and was provided education and counseling during the inpatient stay, as well as plans to proceed directly to rehabilitation services to include dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), motivational techniques, and involvement in 12-step recovery groups, as well as work on coping skills and a relapse prevention plan with identification of triggers. The patient made steady progress with completion of detoxification treatment, though he had continued to display elevated and labile blood pressures requiring safety monitoring and use of clonidine.

The health plan's determination of medical necessity is overturned in whole. The Inpatient Substance Use Detoxification Treatment was medically necessary for this patient.

The patient presented with a diagnosis of severe opioid and stimulant use disorders with severe psychosocial stressors with limited support and functional impairments.
The presenting clinical features and history and general medical concerns did warrant the admission and continued inpatient level services with medical monitoring in this case scenario in keeping with the appeal. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through completion could not have been provided at a lower level of care in this case scenario.
 Withdraw symptoms were managed with buprenorphine requiring monitoring and as needed (PRN) medications, as well as the availability of comfort medications. 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.