Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder
Treatment: Inpatient substance abuse treatment
The insurer denied inpatient substance abuse treatment.
The determination is overturned.

The patient presented for detoxification and substance-related services. He has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (crack cocaine), and cannabis (marijuana) class substances of abuse. He has a history of multiple detoxification treatment episodes with the more recent with a brief rehabilitation treatment and relapse. He was using one-fifth of cognac on a continuous daily basis together with up to ten bags of heroin, as well as tobacco (12 pack per day), two blunts of marijuana, and $100 worth of cocaine daily.

At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. He denied current legal issues. He was unemployed with limited family support and reported severe psychosocial stressors within the primary support, social environment, and housing domains with unemployment and social security disability. The patient reported functional decline as the substance abuse/disease had progressed which again prompted his self-referral for detoxication treatment in the context of at least twenty prior detoxification treatment episodes and a pattern of back-to-back admissions.

The patient provided no past history of withdrawal seizures or delirium tremens, but did report severe alcohol withdrawal symptoms. He was medically screened and admitted for inpatient level detoxification with plans for a five-day detoxification treatment with Valium and Suboxone and supportive measures. Withdrawal symptoms were mild to moderate with a clinical opiate withdrawal (COWS) and Clinical Institute Withdrawal Assessment (CIWA) scale scores up to 15 and 21, respectively, on day two of his inpatient stay. He displayed a headache, tremor, nausea and bone aches with restlessness and anxiety.

The patient has no history of psychiatric disorder or treatment, and no history of suicidal or self-harming behaviors. There were no acute medical issues in this case other than the alcohol and opioid withdrawal. The patient was tobacco dependent at one-half pack per day, as noted, and he had a history of human immunodeficiency virus (HIV) positivity with no active signs of HIV.

On mental status examination, there were no severe symptoms and no safety concerns with regard to risk of harm to self or others. The patient displayed poor insight despite his extensive treatment history, impaired judgment due to the substance use, and poor control of impulses. He demonstrated symptoms of anxiety with generalized symptoms including insomnia and labile affect, together with symptoms related to the alcohol and opioid withdrawal, as noted.

The patient was admitted for inpatient treatment with a detoxification protocol. He received tapering dosages of Valium and Suboxone and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, and insomnia.

The patient's hospital course progressed without incident. His vital signs remained normal with occasional variability and the patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout his hospital course. He was socially withdrawn initially, but participating in counseling and educational sessions. The patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment. Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment. He received case management services and planning for clinically appropriate aftercare with discharge.

The case records, health plan documents, appeal documents, correspondence from the treatment facility, correspondence from the health plan, as well as the health plan's rationale for the denial of certification for coverage of the requested treatment were reviewed. This review is a New York State review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.

The issue under review is inpatient substance abuse treatment.

The requested health service/treatment of inpatient substance abuse treatment is medically necessary for this patient.

The patient was using large quantities of alcohol and heroin on a daily continuous basis together with cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. The patient's social environment was not conducive to an effective detoxification and the patient had struggled with withdrawal symptoms which were being effectively addressed with Valium and Suboxone protocols and supportive measures. The patient had associated clinical features that included a lack of sober supports and limited insight, impaired judgment and poor control of impulses.

The adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the hospital admission and the continued structure of an inpatient level setting with withdrawal management, psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria referenced below.