Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient Detoxification Services.
The insurer denied the Inpatient Detoxification Services.
The denial is overturned. 

The patient is a adult male who presented to the emergency department requesting detoxification treatment and was medically screened and admitted to acute inpatient level care in order to address substance use disorder with opioid, alcohol, and sedative-hypnotic-anxiolytic class substance use disorders. The patient had been using up to six shots of vodka together with two sticks of Xanax or Klonopin. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatments and was receiving medication assisted treatment of opioid use disorder with Suboxone. His self-referral for treatment was prompted by multiple stressors and general health concerns.

The patient presented with acute co-morbid general medical issues that included history of hepatitis C and B positivity with normal liver functions and other chronic conditions including chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), chronic venous stasis of a lower extremity and mitral valve regurgitation. He was prescribed aspirin (ASA) and pantoprazole. 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. His onset of mild withdrawal symptoms included anxiety, motor agitation, nausea, sweats, and tremor, scoring an 8 on the CIWA (Clinical Institute Withdrawal Assessment) scale.

The patient engaged with detoxification treatment; he was cooperative with the tapering dosages of Klonopin and received vitamin replacement therapy. Withdrawal symptoms remained mild, but persisted, requiring PRN (as needed) medication and monitoring. The patient completed the detoxification treatment and was discharged with clinically appropriate aftercare.

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 alcohol and a benzodiazepine on a daily continuous basis 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. The patient 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. Additionally, the patient presented with significant medical conditions and was in treatment for opioid use disorder with Suboxone.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of PRN medications. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorders 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, the 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 NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.