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 requesting detoxification treatment and admitted to acute inpatient level care in order to address substance use disorder with opioid (heroin), alcohol, and stimulant (cocaine) class substances, as well as use of cannabis, hallucinogen and sedative-hypnotic-anxiolytic class drugs of abuse. The patient had been using up to 12 bags of heroin with intravenous (IV) administration together drinking three pints of liquor daily. He was using cocaine intermittently with use of crack or freebase cocaine with IV administration of up to one gram. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification and substance use disorder treatments with up to twenty to fifty treatment episodes many of which were back-to-back. His self-referral for treatment was prompted by multiple stressors including housing, primary support, social environment and other psychosocial domains.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone and Librium, and clonidine as needed, and prn medications for comfort, as well as vitamin replacement therapy and use of Depakote for seizure prophylaxis. The program provided for case management with referral to sober housing and access to rehabilitation treatment that included comprehensive evidence-based treatments. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and, involvement with counseling and milieu activities including peer support and education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal during his brief stay. 

Yes, the proposed treatment, inpatient substance abuse treatment, was medically necessary for this patient.

The requested Inpatient admission and continued treatment 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 heroin, together with alcohol on a daily continuous basis with intermittent use of other substances of abuse including cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; 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 had a positive drug screen that included opioids and benzodiazepines, as well as PCP and cocaine. He had moderate and persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient detoxification treatment and withdrawal management of this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of as needed (PRN) medications. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments 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, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.