Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male who presented for detoxification treatment. He was medically screened and admitted to acute inpatient level care beginning in order to address substance use disorder with opioid, alcohol, cannabis, and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using fentanyl administered with smoking and alcohol on a daily continuous basis, as well as intermittent use of methadone, 
cannabis/marijuana, and benzodiazepines. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatments with 
relapses and associated legal problems. His vital signs included elevated pulse as high as 123 reflecting withdrawals from alcohol, and his Clinical Institute Withdrawal Assessment (CIWA) 
was scored in the mild to moderate range with a clinical opiate withdrawal scale (COWS) score of 6-7. He reported nausea, tremor, sweats, altered sensorium, agitation, and anxiety.
Denial of coverage was based on medical necessity and plan guidelines indicating that there were no serious withdrawals or abnormal vital signs or history/risk of withdrawal complications. The appeal asserted that the admission and treatment was medically necessary and met plan criteria with abnormal vital signs, general medical comorbidities, and withdrawal risk. The appeal indicated that treatment could not have occurred with a lower level of care.

The requested health service was 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 opioid and alcohol class substances on a daily continuous basis with intermittent use of other substances of abuse 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 tetrahydrocannabinol (THC). 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. There were general medical comorbidities that warranted inpatient treatments including intravenous antibiotics and supportive measures with ongoing evaluations including imaging studies.
Thus, the need for detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of as needed (prn) medications and indicated treatment of the cellulitis and pain. The patient's history of substance abuse (frequency 
and quantity) together with the severe psychosocial stressors and functional impairments 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 if the 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, and New York State instruction for medical necessity reviews including the appropriate application of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Tool that requires the patient in this scenario default to the higher level of care. Therefore, the requested health service was medically necessary for this patient.