Appeal type: Medical necessity
Decision: Upheld

The patient is a female with substance use disorders and mood disorder who was admitted to an inpatient detoxification unit. The health plan denied payment for part of the stay based on lack of medical necessity.

On initial presentation the patient indicated using heroin, crack cocaine and alcohol daily. The amount of use listed varies across notes. Her alcohol level was negative. Her urine was positive for opiates, benzodiazepines, and cocaine. The included admission notes do not comment on use of benzodiazepines and why her urine might be positive for this. Her initial vitals including normal pulse of 88 and elevated blood pressure of 148/83. The initial evaluation by an LPN at 1533 hrs. states that she is not yet having any symptoms of withdrawal. The note by the physician signed at 1706 hrs. indicates she was now complaining of insomnia, anxiety, yawning, tremors, irritability, headache, and teary eyes. Her physical exam was documented as normal and her initial Clinical Institute Withdrawal Assessment (CIWA) was 8 and Clinical Opiate Withdrawal Scale (COWS) 15. The admission note says she was admitted for detoxification from alcohol, benzodiazepines, and opiates.

She was admitted to the detoxification unit and put on a five day Librium and Methadone taper. No repeat CIWA or COWS scores were included for review. No daily physician progress notes were included. Discharge day notes were included. She refused Librium for three consecutive doses,  told nursing she did not need it and the Librium taper was stopped. She received the methadone taper but refused the final dose. During the admission she has some mild complaints of headache, sweating and anxiety. Her pulse ranged from 80-91 and her blood pressure ranged from 100-148/64-93. Nursing notes indicate she had no behavioral issues and was visible on the unit. She discharged to return to the halfway house she was living at before and to follow up with outpatient providers. She had an outpatient intake for ongoing substance use disorder treatment.
The subject under review is the medical necessity of the inpatient stay for the denied dates of service.
The health plan's determination is upheld.

The patient is recorded to have a long history of multiple substance use disorders. Of the substances she reportedly uses withdrawal from benzodiazepines and alcohol can be dangerous. However, her use of benzodiazepines is not described in the chart. Her initial CIWA was only 8 which is consistent with mild withdrawal. She has no history of complicated withdrawal per the charting. Withdrawal from cocaine and opiates can be uncomfortable but is not dangerous. She has no documented medical conditions that would elevate her risk in withdrawing from cocaine or opiates (e.g. no cardiac conditions). The admission notes for this stay are primarily templated notes that do not include a full review of substance use disorder symptoms and do not include a discussion of the medical decision making of the physician in determining this level of care. She is noted to have psychiatric diagnoses but is on medications and indicated they were effective, and she continued taking these home medications during admission without any evidence of acute psychiatric symptoms.

The result of the admission LOCADTR submitted by the facility was for inpatient detoxification, but that determination included findings in the LOCADTR that are not supported by the clinical charting.

More specifically, the admission LOCADTR completed by the admitting physician includes that she has failed detoxification at a lower level of care. However, the charting documents her last detoxification as being inpatient at CMAC in 2018 and does not comment on any more recent treatment at a lower level of care or current care. The LOCADTR report also indicates that she lacks support from the outpatient setting for early abstinence. However other documentation indicates that she is living at a halfway house and returns there on discharge. Thus, she had stable housing in a setting familiar with her conditions. The admission LOCADTR indicates that she is not appropriate for outpatient level of care for detoxification services but provides no narrative explanation of this in any note.

This reviewer completed an admission LOCADTR based on what information was documented in the chart and the result was for outpatient rehabilitation with outpatient detoxification services.