Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse/Addiction. 
Treatment:  Substance Abuse: Inpatient.
 
The insurer denied inpatient substance abuse treatment.  The denial was overturned in whole.

The patient is a male, who presented for detoxification and substance-related services.  The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (cocaine), and cannabis class substances.  He had a history of multiple substance use disorder treatment episodes with the more recent occurring three years ago, but relapsed and was using a pint of brandy plus beer on a continuous daily basis together with six bags of $100 worth of cocaine and up to 5 bags of heroin with intranasal administration, as well as tobacco (1 pack per day) and one blunt of marijuana daily.  Again, he had multiple prior substance use disorder treatments including a rehabilitation treatment episode three years ago with a chronic relapsing course since young adulthood.  At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment.

There were no severe symptoms on mental status examination and no safety concerns with regard to risk of harm to self or others.  The patient displayed poor insight despite his extensive treatment history, and impaired judgment due to the substance use, and poor control of impulses.  He demonstrated symptoms of anxiety with generalized symptoms including insomnia, and labile affect together with tremor and other symptoms related to the alcohol and opioid withdrawal with Clinical Institute Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Scale (COWS) scales scores of six.

The patient was admitted for inpatient treatment with detoxification protocol.  He received tapering dosages of Librium and Methadone and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, and insomnia.  The patient's hospital course progressed without incident.  Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout his brief hospital course.  He was participating in counseling and educational sessions and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.  Arrangements were being made for a direct referral to outpatient rehabilitation substance use disorder treatment; however, the patient left treatment against medical advice.

The health plan's determination of medical necessity is overturned in whole.

The inpatient substance abuse treatment and withdrawal management and monitoring and other medical services is medically necessary for this patient.

The inpatient detoxification treatment and withdrawal management and monitoring 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 large quantities of multiple substances on a daily continuous basis that did warrant the admission and the continued 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.

Medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, including the appropriate application of NY Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria-referenced below.