Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Services
The insurer denied the Inpatient Detoxification Services
The denial is upheld. 

The patient is an adult male. He presented with a request for detoxification services. The patient reported using opioid (heroin), cocaine, and alcohol on a continuous daily basis. He presented with a blood alcohol level of zero and mild symptoms of withdrawal with a COWS (clinical opiate withdrawal scale) scale score of 6. He had received multiple past substance use disorder treatments including the most recent detoxification a year prior with step down to rehabilitation treatment. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. The patient had a history of psychiatric disorders and treatment for schizophrenia and a bipolar mood disorder with a comorbid unspecified anxiety disorder; he was in outpatient treatment with Prozac, Seroquel, Depakote and Risperdal at clinically appropriate dosages though his compliance with psychotropic medications was questionable.

On Mental Status Examination, the patient was cooperative with good eye contact. Speech was clear and thought production was linear and logical. There were no severe symptoms on mental status examination such as thought disorder, cognitive impairment, severe mood disturbance, psychosis or perceptual disturbance, or suicidal ideation.  He presented with anxiety/irritability and complaints of insomnia as well as nasal stuffiness. He had fair control of his impulses. Vital signs tended to normalize following admission and throughout his inpatient stay with treatment including amlodipine and prn clonidine.

The patient was admitted for inpatient detoxification with a Methadone taper. The patient's hospital course progressed without incident. 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 needed) use of clonidine and comfort medications.  He was discharged against medical advice with recommendations for clinically appropriate aftercare.

The health plan denied the entire inpatient stay 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) 3 Guidelines/Criteria indicating that the withdrawal symptoms were mild and that treatment could be appropriately provided at the residential level of care. The health plan referenced no acute general medical or psychiatric issues including safety concerns or psychosis, and, that the patient had an outpatient mental health provider with medication management.

In its appeal, the treatment facility indicated that LOCADTR (level of care for alcohol and drug treatment referral) Criteria were met for inpatient level treatment and that psychosis was not considered an exclusion-criteria in this case, and that the treatment was clinically appropriate and necessary for this patient accordingly.

No, the Inpatient Detoxification Services was not medically necessary in keeping with NY State LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria.
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. The acute inpatient treatment of this patient's substance use disorder 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. 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 on the basis of those clinical features-as the health plan asserts in the denial. 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 consistent with the health plan's reason for denial, including the application of New York State LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria and consistent with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria, as referenced below. The appeal that the LOCADTR (level of care for alcohol and drug treatment referral) Criteria are met is not effectively shown in this case.

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.  There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. The Inpatient substance abuse treatment for detoxification and withdrawal management and other medical services were therefore not medically necessary in this case scenario, as the health plan asserts. NY State LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below, and contrary to the appeal from the treatment facility.