Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder; schizoaffective disorder, depressive type
Treatment: Inpatient psychiatric admission
The proposed treatment was medically necessary for this 
patient.

The requested benefit of the inpatient admission 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 large quantities of opioid/heroin together with alcohol and daily use of a benzodiazepine anxiolytic (Xanax) and cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring; 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's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the admission and continued detoxification treatment of this patient's substance use disorders, and other treatment to address medical co-morbidity and co-occurring psychiatric disorder, did necessitate the continued structure of an inpatient level detoxification setting and monitoring. The patients history of substance abuse (frequency and quantity) together with the drug-infested social environment, and severe psychosocial stressors and functional impairments together with general medical conditions 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 continued 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 NY State OASAS LOCADTR 3.0 Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of the inpatient admission was medically necessary in this case scenario, and is therefore a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant the admission and continued inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification treatment through discharge could not have been safely or 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 ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.