Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission
The proposed treatment, continued inpatient admission, was medically necessary for this patient.

The requested benefit of continued inpatient admission could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin with up to three bags intermittently and was using non-prescribed methadone daily that did warrant the admission and the continued inpatient level detoxification with withdrawal management and inpatient level monitoring. Detoxification with a methadone taper, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms including persistent anxiety and elevated blood pressures that were being effectively addressed with methadone taper and supportive measures and as needed (PRN) medications provided during the time interval under review. The patient presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses that also supported the continued inpatient level detoxification in order to prevent relapse and complete his detoxification which allowed for his preparation for a recovery effort and referral to rehabilitation services. 

Thus, the continued detoxification treatment of this patient's substance use disorders did warrant and require the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors, and functional impairments do 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 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, ASAM Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines-referenced below.

The requested benefit of continued inpatient admission is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The continued inpatient level treatment through discharge could not have been effectively provided with lower level services, as noted 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 consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.