Appeal type: Medical necessity
Decision: Overturned

The patient is a male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe sedative-hypnotic-anxiolytic (benzodiazepine) and opioid (heroin) use disorders. He was using up to 10-20 bags daily of heroin together with Xanax with two to three sticks or 4-6 milligrams (mg) daily. The patient had moderately severe anxiolytic and opioid withdrawal at the time of admission with a Clinical Opiate Withdrawal Scale (COWS) scale score of 16. He had severe withdrawal symptoms in the past requiring detoxification services on multiple occasions with the more recent detoxification in 2018.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with Librium and Methadone taper, vitamin replacement therapy, and medical monitoring; the patient was offered smoking cessation treatment and nicotine replacement. Following his first day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. He continued to report anxiety, aches and nausea treated with comfort medications. He was prescribed fluoxetine and Vistaril for depression and anxiety. As well as omeprazole and a Ventolin inhaler for his general medical conditions. Vitamins were continued, as well as comfort medications and monitoring, and assistance with daily activities. He was prescribed gabapentin at therapeutic dosages to address the chronic pain.

The patient was discharged against medical advice on the third hospital day with recommendations for clinically appropriate aftercare.  He declined these recommendations indicating that he was not ready yet to engage in rehabilitation substance-related treatment and was planning to "get high."

The health plan's determination is overturned.

The proposed 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. This patient's substance use disorders and clinical features and treatment dimensions 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 with multiple substances of abuse, and the co-occurring anxiety and depressive disorder and associated psychosocial stressors and impairment of functioning. The patient had no reasonable recovery or treatment environment and no sober supports and was at high risk for relapse. Withdrawal symptoms were managed with tapering dosages of benzodiazepine and methadone requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and nicotine replacement and vitamin replacement therapy to prevent the onset of encephalopathy. 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 to rehabilitation substance use disorder treatment. The mood and anxiety disorder and chronic pain were managed with medications a clinically appropriate. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder, psychiatric and general medical treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.