Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Detoxification Admission.

The insurer denied the Inpatient Detoxification Admission.  The denial is upheld.

The patient is a adult male. He presented with a request for detoxification services to address severe opioid use disorder. The patient was using up to 10 bags of heroin on a continuous daily basis with IV (intravenous) administration and was using non-prescribed methadone 20 mg (milligrams) intermittently. His opioid use was longstanding beginning prior to admission. He presented with a COWS (clinical opiate withdrawal scale) scale score of 9 and CIWA (clinical institute withdrawal assessment) scale score of 7. He presented with normal vital signs and mild tremors and anxiety. The patient provided no history of severe drug withdrawal symptoms or overdoses.

The patient has an extensive history of detoxification treatment episodes with at least one treatment episode with rehabilitation substance use disorder treatment. The patient had a history of psychiatric disorder best characterized as bipolar depression diagnosed, but with no current treatment. There were no acute or chronic general medical problems; he had a history of hepatitis C positivity and was tobacco dependent.

The patient was medically screened and admitted for inpatient level detoxification with plans for a five-day detoxification treatment episode with Methadone, vitamin replacement therapy and comfort medications, as well as the availability of nicotine replacement. His laboratory assessment was normal or unremarkable as well as his physical examination that was consistent with history. His drug screen was positive for opioids/opiates.

The patient was admitted for inpatient detoxification with plans for a Methadone protocol. The patient's hospital course progressed without incident. Vital signs were consistently normal and the patient was in no apparent distress. The patient slept and received meals. His monitoring occurred without incident, and he attended group sessions and received counseling with recommendation for clinically appropriate aftercare. He received vitamin replacement therapy and prn (as the need arises) use of clonidine and Benadryl. He was discharged against medical advice without explanation, and referral for residential rehabilitation treatment was recommended.

The health plan denied coverage on the basis of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Criteria indicating that criteria were not met and that the patient had no general medical or biopsychosocial issues requiring inpatient level care. Outpatient treatment was recommended with the denial determination.

The appeal was on the basis of the New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Criteria and the patient's comorbid depression and lack of coping skills.

No, the Inpatient Detoxification Admission was not medically necessary.
The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care, as the health plan asserts in the denial determination. The treatment of this patient's substance use disorders did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder and past history of bipolar depression. There was no co-occurring psychiatric disorder or psychiatric symptoms that would have warranted inpatient level treatment. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria, as referenced below.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.

In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive setting. The patient displayed no serious disturbance of mental status. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted in the answer to question 2. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services, as the health plan asserts in the denial and New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria were not met contrary to the appeal.