Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient Substance Abuse Treatment.
The insurer denied the Inpatient Substance Abuse Treatment.
The denial is overturned.

The patient is a male who presented for detoxification and withdrawal management. The patient has a history of severe substance use disorders beginning in early adolescence with daily use of alcohol, stimulants (crack cocaine), and cannabis (marijuana) class substances of abuse, as well as use of phenylcyclohexyl piperidine (PCP). He has a history of multiple detoxification and rehabilitation treatment episodes with relapses. He was using up to four pints of various liquors on a continuous daily basis together with twelve blunts of marijuana and $200 worth of cocaine daily.

The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of counseling and comfort medications and as needed (PRN) medications prescribed for pain, anxiety, and insomnia, as well as medication assisted treatment with Campral. 

The patient's hospital course progressed without incident. Vital signs remained normal with occasional variability, and the patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout his hospital course. He was participating in counseling and educational sessions. During the last two days of his treatment, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment. Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment. He was discharged with recommendations for continued medication assisted treatment and involvement with alcoholics anonymous (AA) and narcotics anonymous (NA) self-help groups for support of a recovery.

At the time of presentation to the emergency department, the patient was requesting detoxification and subsequent referral for rehabilitation substance use disorder treatment. He denied current legal issues. He was unemployed with limited family support, and homeless living with his mother; he reported severe psychosocial stressors within the primary support, social environment, and housing domains with unemployment-as noted. The patient reported functional decline as the substance abuse/disease had progressed which again prompted his self-referral for detoxication treatment in the context of at least four prior detoxification treatment episodes and several rehabilitation treatments with a pattern of relapses functional impairments.

Yes, the proposed treatment and requested services were medically necessary for this patient in keeping New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and prevailing standards of medical practice.

The requested benefit of inpatient detoxification treatment, withdrawal management, monitoring and other medical services 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 alcohol and other drugs of abuse (crack cocaine and marijuana) on a daily continuous basis together with intermittent use of PCP (phenylcyclohexyl piperidine) that did warrant the admission and the continued 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 an effective detoxification, and the patient had struggled with withdrawal symptoms which were being effectively addressed with a Librium protocol and supportive measures. The patient had associated clinical features that included lack of sober supports and functional impairments. Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did warrant the hospital admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (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 or general medical complications such as seizures 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-referenced below. The health plan's denial on the basis of New York LOCADTR Criteria is not reasonable and attempting detoxification with residential or lower-level treatment is not in the best interest of the patient or safe in this case scenario.

The health plan's denial on the basis of New York LOCADTR Criteria is not reasonable, and attempting detoxification with residential or lower-level treatment, as the health plan recommended, is not in the best interest of the patient or safe in this case scenario. The requested benefit of Inpatient detoxification treatment and withdrawal management and monitoring and other medical services is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower-level services. 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, LOCUS Guidelines, and application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.