Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient Stay

Summary:
The patient is an adult male requesting detoxification treatment and medically cleared and admitted to acute inpatient level care in order to address substance use disorder with opioids (heroin and hydrocodone), alcohol, cannabis (marijuana), and stimulant (cocaine) class substances, as well as use of cannabis and sedative-hypnotic-anxiolytic class drugs of abuse. The patient had been using up to 20 bags of heroin with IV administration together with intermittent use of hydrocodone, and the patient was binge drinking two to three times per week together with 2 mg of Xanax. He was using two grams of cocaine and two marijuana joints daily. He denied history of withdrawal seizures or delirium tremens, but reported frequent blackouts and at least two prior overdoses including a recent overdose in his mother's home. He had a history of prior detoxification and substance use disorder treatments with medication assisted treatment up until two months prior to admission. His medication assisted treatment had included Vivitrol and Suboxone without sustained benefits. His self-referral for treatment was prompted by multiple stressors including housing, occupational, primary support, legal, social environment and other psychosocial domains.

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, non-prescribed hydrocodone and cocaine together with alcohol, Xanax and cannabis with use of these substances on a daily continuous or intermittent basis 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 persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms during the time interval under review 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 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, 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 3.0 Tool that requires the patient in this scenario default to the higher level of care.