Appeal type: Medical necessity
Decision: Overturned

The patient is a male who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (cocaine), and cannabis (marijuana) class substances of abuse. He had a history of multiple substance use disorder treatment episodes with the more recent earlier in the year, but relapsed and was using a six pack of beer on a continuous daily basis together with one gram of cocaine and up to 20 bags of heroin with intravenous (IV) administration, as well as tobacco (12 pack per day) and one blunt of marijuana daily. Again, he had multiple prior substance use disorder treatments including a rehabilitation treatment episode several months prior to admission with a chronic relapsing course since adolescence. 

At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. He denied current legal issues. He was homeless and unemployed and reported severe psychosocial stressors within the primary support, social environment, occupational and housing domains. The patient reported functional decline as the substance abuse/disease had progressed which prompted his self-referral for detoxication treatment and request for rehabilitation services.

The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and Methadone 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. Vital signs remained normal, and the patient reported mild tremor, 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 He was socially withdrawn initially but participating in counseling and educational sessions.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. However, the patient left treatment against medical advice.
Again, the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium, methadone and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.

The health plan's determination is overturned.

The requested benefit of continued inpatient substance abuse treatment with detoxification 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 large quantities of heroin together with alcohol and cocaine and marijuana 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. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium, methadone and supportive measures. The patient had associated clinical features that included lack of sober supports and limited insight and poor control of impulses with regard to the substance use.

Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patients 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, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below including the appropriate application of NY Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria-referenced below.