Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance Abuse 
Treatment: Inpatient Hospital Stay 
The insurer denied the inpatient hospital stay. 
The health plan's determination is overturned. 

The patient is a male who was self-referred and admitted to acute inpatient level services for detoxification and withdrawal management of opioid (Percocet) use disorder. He was using up to 90 milligrams (mg) of Percocet daily for the past 2-3 years with escalating use since. The patient had experienced severe drug and alcohol withdrawal symptoms in the past and he denied inadvertent illness. He had received detoxification and rehabilitation treatment in the past with a history of eight years of sobriety actively participating in Narcotics Anonymous (NA). The patient was tobacco dependent and was using cannabis with one joint per day for relaxation. The patient has no history of a co-occurring psychiatric disorder, and denied psychiatric hospitalization, or suicidal or self-harming behaviors. 
The physical examination and laboratory assessment were normal or unremarkable except for a positive drug screen consistent with history and normal vital signs that remained normal throughout the inpatient stay. His blood alcohol level was zero. The patient presented with diaphoresis, body aches, chills, fatigue, restlessness, and anxiety. He had no severe psychiatric symptoms such as mood disturbance, psychosis, perceptual disorder, or cognitive impairment. 
Following his first day of treatment, the patient began to participate in counseling and educational sessions, as he was feeling better. His mental status examination included persistent symptoms of anxiety with associated symptoms of insomnia. During his inpatient stay, the patient demonstrated no severe symptoms such as mania, psychosis, perceptual disturbance, or severe cognitive impairment. The patient completed the detoxification treatment without complications. The patient was discharged with referral for clinically appropriate aftercare including plans for rehabilitation treatment and resumption of involvement with 12-step recovery groups. 

The presenting clinical features and history and risk for withdrawal complications did warrant the admission and continued inpatient level services with a safe detoxification protocol and medical monitoring. 

The requested health service/treatment of inpatient hospital stay was medically necessary for this patient. The inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care, as noted in the answer to question 1 above. The adult inpatient treatment of this patient's substance-related disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders and the associated psychosocial stressors and impairment of functioning. 
Withdrawal risk was managed with tapering dosages of methadone and monitoring and as needed (prn) medications, as well as the availability of comfort medications and vitamin and nicotine replacement therapy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition for appropriate rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with inpatient level services and withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse or remain in treatment if detoxification and treatment were attempted at a lower level of care.