Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse.
Treatment:  Inpatient Substance Abuse.

The insurer denied the Inpatient Substance Abuse.  The denial is upheld. 

The patient is a male, who was admitted to inpatient level services for detoxification treatment, stabilization and withdrawal management of opioid use disorder (heroin and Fentanyl), and comorbid sedative-hypnotic-anxiolytic use disorder (Xanax).  The patient reported no past history of withdrawal seizures or delirium tremens and had no general medical complications of his use that had begun in adolescence and progressed.  He reported using up to ten bags of heroin daily with intravenous (IV) administration, and intermittent use of one bar of Xanax up to three times per week, as well as occasional use of methadone 20 milligrams (mg) and Fentanyl and cocaine.  He had prior detoxification treatment episodes, including one within the last year, and up to 21 substance use disorder treatment episodes this year alone.  He reported no period of sobriety in the past with relapses following each treatment episode.  At the time of presentation for admission, the patient's Clinical Opiate Withdrawal Scale (COWS) score was at six, reflecting mild or minimal withdrawal symptoms that included chills, abdominal cramping, rhinorrhea, anxiety, irritability and restlessness.

There were no acute psychiatric issues in this case or past psychiatric treatment or hospitalization.  There were no acute general medical issues in this case.  The patient is tobacco dependent with 14 pack per day use.

Mental status examination on admission was free of severe symptoms.  Insight and judgment were considered fair though impaired due to the substance use disorders.  The patient was deemed to be motivated to enter detoxification treatment.  He denied suicidal ideation or aggressive behavior.  Speech was clear with linear and logical thought.  Mood was euthymic with anxiety and insomnia.  There was no evidence of mania, thought disorder, psychosis, perceptual disturbance or cognitive impairment.

Withdrawal symptoms were mild and were not reported throughout the inpatient stay with the availability of comfort medications.  There were no reported abnormalities on physical examination, though he had a body mass index (BMI) of 19.7 and was prescribed ensure supplements three times per day.  The patient was nicotine dependent, as noted with the availability of nicotine replacement therapy and smoking cessation counseling.

The patient is single and unemployed and lives with family.  He has a significant other who also has substance use disorder and was reportedly in treatment.  There were pending legal issues complicating this case.

The patient was admitted and placed on a detoxification regimen with tapering dosages of methadone, and, the patient was provided with comfort medications per protocol.  The detoxification was uncomplicated with regard to withdrawal management.  He was sleeping and eating without distress.  He was taking care of his daily needs without assistance.  He had the opportunity to participate in counseling and education, as the program would allow, as well as recovery groups and focus on relapse prevention and better coping.  The case manager discussed referring the patient for rehabilitation treatment and aftercare including consideration of medication assisted treatment.  He was discharged, indicating that he had family issues that needed his attention, and he was discharged with recommendations for clinically appropriate aftercare.

No, the proposed treatment, inpatient substance use disorder treatment and services, was not medically necessary for this patient.

The patient in this case was using heroin on a continuous daily basis together with intermittent use of Xanax and daily use of tobacco.  The patient presented as cooperative and motivated to receive detoxification treatment in the absence of severe symptoms of opioid withdrawal.  Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation or aggressive impulses at the time of admission.  The patient was medically cleared, and there were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services.  Again, the withdrawal symptoms were not reported to be severe and were mild as assessed with the Clinical Opiate Withdrawal Scale (COWS) scale of opioid withdrawal.  Thus, the patient's clinical presentation was not serious enough to warrant the admission and continued inpatient level treatment or 24-hour monitoring.  Additionally, the patient did not present with severe psychosocial stressors that would have posed a problem if detoxification treatment was provided in a less restrictive treatment setting at a lower level of care.  Therefore, the detoxification treatment (and referral/treatment for/with rehabilitation services) could have been effectively provided at a lower level of care, as the health plan asserts. 

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as NY State instruction for this medical necessity review and 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 Guidelines/Criteria.

The substance use disorder detoxification services and withdrawal management could have been safely and effectively provided at a lower level of care in this case scenario.  Thus, the requested service of substance use disorder inpatient admission for detoxification and other medical services is not reasonable in this case scenario.  The patient's presentation and clinical features did not warrant the intensity of inpatient level services or inpatient level structure or 24-hour monitoring in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines (NY State Office of Alcoholism and Substance Abuse Services [OASAS] Level of Care for Alcohol and Drug Treatment Referral [LOCADTR 3.0] Criteria/Guidelines), referenced below.