Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adult male. He presented for detoxification treatment. He was medically screened and admitted to inpatient level care to address substance use disorder with opioid (heroin) and stimulant (cocaine) class substance use disorders. The patient had been using heroin with 10 bags daily for several years without any period of sobriety. He has no history of withdrawal seizures or delirium tremens. He had a history of prior detoxification treatment episodes with the last occurring three weeks prior to presentation. He had used 20 bags of heroin the morning of his presentation and presented with a clinical opiate withdrawal scale (COWS) score of two consistent with history. He indicated that his wife had kicked him out of their apartment and issued an ultimatum to get treatment. The patient has a history of psychiatric disorder with bipolar mood disorder and attention-deficit/hyperactivity disorder (ADHD) with outpatient medication management and indication he that was not taking his home medications olanzapine, and gabapentin. There was no mention of general medical issues except for hepatitis C positivity without treatment and untreated hypertension. He was tobacco dependent at one-half pack per day. There was no report of a thought disorder, mania, psychosis, or cognitive impairment. The patient did not present with suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses as indicated by continued use despite high-risk for complications and psychosocial consequences including unemployment and homelessness. He had a history of incarceration for attempted murder and assault with no current legal problems. He had unspecified trauma history. The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of methadone and detoxification protocol and as-needed medications for comfort, as well as vitamin supplements. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and involvement with other therapeutic activities with educational sessions to motivate the patient to proceed to rehabilitation treatment. By the third day of detoxification treatment, the patient was discharged against medical advice without explanation for his decision to leave treatment.

The Inpatient Detoxification Services was medically necessary in 
keeping with New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Guidelines required in this case.

The patient in this case was using heroin on a daily continuous basis that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol until discharging against medical advice; 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. The patient's history of substance abuse reflects the seriousness of the substance use disorders and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or complications if the detoxification and withdrawal management were to be attempted at a lower level of care. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, American Society of Addiction Medicine Criteria, and the scientific literature, and the New York State instruction for medical necessity reviews including the appropriate application of the NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Tool that requires the patient in this scenario default to the higher level of care. Therefore, the requested health service is medically necessary.