Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance Abuse
Treatment: Inpatient Detoxification Admission
The insurer denied: Inpatient Detoxification Admission
The denial is overturned

This patient is an adult male who presented for detoxification treatment and was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid, alcohol, and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using one-half pint of liquor together with ten bags of heroin with IV (intravenous) administration and with 2-4 (two to four) mg (milligrams) of Xanax, as well as intermittent use of cocaine with $ (dollars) 20 worth 1-2 (one to two) times per week. He had a history of prior detoxification and substance use disorder treatments with relapses. There was also a history of overdoses and suicidal ideation when using. His self-referral for treatment was prompted by multiple stressors and general health concerns. The patient presented without acute co-morbid general medical issues. He was tobacco dependent. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history. He did not report trauma or abuse history or legal issues. He had good social supports from family. Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses. His onset of mild withdrawal symptoms included anxiety, motor agitation, sweats, body aches, and tremor, scoring a 9 (nine) on the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scale and 10 (ten) on the COWS (Clinical Opiate Withdrawal Scale) scale. The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Ativan and Methadone and as needed medications for comfort, as well as vitamin replacement therapy. The program provided for case management with referral and access to rehabilitation treatment that included comprehensive evidence-based treatments. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and involvement with unit activities including peer support and educational sessions to motivate the patient to proceed to rehabilitation treatment. The patient completed the detoxification treatment and was discharged on Day #7 with referrals for clinically appropriate aftercare.

The proposed treatment of an Inpatient Detoxification Admission is "medically necessary" for this patient. 

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 Xanax on a daily continuous basis with intermittent use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; 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. Moreover, the patient had a positive drug screen that included opioids and Benzodiazepines, as well as Methadone and cocaine. He had mild and persistent withdrawal symptoms, and the patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and poor control of impulses. 
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 the NY State OASAS (Office of Addiction Services and Supports) LOCADTR (Level of Care Determination) Tool that requires the patient in this scenario to be defaulted to the higher level of care.