Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse.
Treatment:  Inpatient substance abuse treatment. 
The insurer denied the Inpatient substance abuse treatment.  The denial is upheld.

The Inpatient substance abuse treatment for detoxification and withdrawal management and other medical services was not medically necessary for this patient.

The patient is an adult male.  He presented with a request for detoxification services less than one week after having received detoxification with step down to rehabilitation services.  The patient was using opioid (heroin), cocaine, alcohol and cannabis 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) score of 12.  He had received multiple past substance use disorder treatments, including the recent detoxification 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 no history of psychiatric disorders or treatment and no acute general medical problems; he had untreated hypertension, and he was hepatitis C positive and tobacco dependent at one-half pack per day for 35 years.  His substance use included up to 15 bags of heroin, 2 grams of cocaine, one pint of alcohol and an unspecified amount of cannabis on a daily continuous basis. 

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.  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.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently, as noted in the clinical summary.  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 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

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 above.  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 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.