Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Medically Supervised Inpatient Detoxification.

The insurer denied the medically supervised inpatient detoxification.  The denial is overturned.

The patient is an adult male requesting detoxification and substance use disorder treatment, who was screened and admitted to acute inpatient level care in order to address substance use disorders with alcohol and stimulant (cocaine) class substances. The patient had a three-year history of substance use with progression of the disease. This patient had a history of one prior detoxification and no rehabilitation treatment episodes. The patient has a history of psychiatric disorder, schizophrenia, and no recent psychiatric hospitalizations. He was currently in treatment for his mental disorder with use of risperidone and quetiapine with questionable compliance with treatment. His withdrawal symptoms included anxiety, sweats, tremor, and restlessness with a CIWA (clinical institute withdrawal assessment) scale score of 10 (mild) and normal vital signs.
During the brief detoxification the patient did engage in counseling sessions focusing on education about the disease model of addiction, and, involvement with milieu activities including peer support and sessions to motivate the patient to proceed to rehabilitation treatment. His stage of change reflected a pre-contemplative stage and he tended to isolate but was social with peers and cooperative with staff. Withdrawal symptoms diminished, and he tolerated the Librium taper. The patient completed the detoxification protocol and was discharged on day #5 with immediate step down for rehabilitation treatment and with plans for medication assisted treatment and recommendations for involvement with self-help recovery groups, and consideration of appropriate treatment for his co-occurring mental disorder. At the time of his discharge, he remained with poor insight with high risk for relapse.

The Medically Supervised Inpatient Detoxification was medically necessary.

The patient in this case was using large quantity of alcohol on a daily continuous basis; and use of cocaine that did warrant 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 and during the time interval under review. Moreover, the patient's social environment was not conducive to detoxification, and the patient struggled with symptoms of anxiety in the context of limited insight, impaired judgment and poor control of impulses. The patient's history of substance use (frequency and quantity) and functional impairments related to a severe and persistent mental disorder (schizophrenia) 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 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 (American Society of Addiction Medicine) Criteria and LOCUS (Level of Care Utilization System) Guidelines, and the scientific literature, referenced below, and, 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.