Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorders
Treatment: Inpatient Detoxification Admission
The insurer denied the Inpatient Detoxification Admission
The denial is overturned.

The patient is an adult male who presented to the emergency department requesting detoxification treatment. He was medically screened and admitted to acute inpatient level care diagnosed with opioid (heroin) and alcohol class substance use disorders. The patient had been using up to two pints of liquor together with intermittent use of three bags of heroin in the context of methadone maintenance treatment at 40 milligrams per day. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatment. His self-referral for treatment was prompted by multiple stressors and general health concerns.

The patient has no history of psychiatric hospitalization or suicidal behavior and was not taking psychotropic medications. He had a history of post-traumatic stress disorder (PTSD).

The patient presented with acute co-morbid general medical issues that included history of hepatitis C and other chronic conditions including chronic obstructive pulmonary disease (COPD) with asthma, lung neoplasm, hypertension, atrial fibrillation and spinal stenosis of the cervical spine. He was prescribed lisinopril, amlodipine, albuterol inhaler, and baclofen. Laboratory assessments were unremarkable or normal with a positive drug screen consistent with history, as well as positivity for tetrahydrocannabinol (THC).

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with a full range of affect. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses. 

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Librium and use of methadone and as needed (PRN) medications for comfort, as well as vitamin replacement therapy and the availability of nicotine replacement in the context of tobacco dependence. The program provided for case management with referral and access to rehabilitation treatment that included comprehensive evidence-based treatments. During the brief 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 education sessions to motivate the patient to proceed to rehabilitation treatment. The patient did not complete the detoxification protocol and left treatment noted to be in "no apparent distress."

The appeal was on the basis of medical necessity indicating that the severity of substance-related disorders and comorbid general medical conditions did require inpatient level care and monitoring. 

The denial was on the basis of medical necessity indicating that there were no complicated withdrawal symptoms and no history of withdrawal seizures or delirium tremens. The denial determination referenced the lack of acute medical or psychiatric symptoms and noted that the patient was motivated and engaged in treatment.

The issue under review is inpatient detoxification and withdrawal management and other medical services.

Yes, the proposed treatment 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 heroin intermittently while in a methadone program together with large quantities of alcohol on a daily continuous basis that did warrant inpatient level detoxification, withdrawal management and monitoring for the duration of the inpatient stay.  Moreover, the patient had a positive drug screen that included opioids and tetrahydrocannabinol (THC), as well as the alcohol use. The patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and poor control of impulses. Moreover, the patient presented with an array of general medical conditions.

Thus, the adult inpatient 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. 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. 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 as referenced below, and with 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.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested benefit of inpatient substance abuse treatment is medically necessary and clinically appropriate in this case scenario, and is therefore a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications, together with counseling and educational sessions and peer support. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition though the patient did discharge against medical advice prior to completion of the detoxification protocol. Moreover, the admission and the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower-level services, as noted in the answer above. 

Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including the American Society of Addiction Medicine (ASAM) Criteria and the New York 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.