Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction.
Treatment: Substance Abuse Inpatient.
The insurer denied: Inpatient substance abuse treatment.
The denial is: Overturned in whole.

The patient is a male who was admitted to acute inpatient level services for monitoring and detoxification and withdrawal management of alcohol, stimulant (cocaine), cannabis, sedative-hypnotic-anxiolytic (benzodiazepine), and opioid (heroin, buprenorphine, and prescription opiates) use disorders. He was using heroin and oxycontin with intranasal administration/vaping as well as daily use of buprenorphine obtained from a friend, small amounts of alcohol with one to two beers one to two times per week, marijuana one to three times per month, and $20 worth of cocaine with intranasal administration one to two times per week. He was regularly using 2 milligrams (mg) of non-prescribed Xanax in order to self-treat anxiety; records indicated that this was his drug of choice. The patient had experienced mild to moderately severe alcohol/anxiolytic and opioid withdrawal at the time of admission with withdrawal symptoms that included joint pain, aches, nausea, sweats, and tremor, as well as anxiety, irritability, and insomnia. 

The patient reported that he had an anxiety disorder. He denied current psychiatric treatment or hospitalization, or suicidal or self-harming behaviors. He reported an unintentional overdose with detoxification and substance use disorder treatment and immediate relapse.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a Librium and Suboxone taper, vitamin replacement therapy, and medical monitoring; the patient was tobacco dependent and offered smoking cessation treatment and nicotine replacement. 

The patient was initially ambivalent about his treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. He did continue with detoxification treatment was maintained on seizure precautions. 

The subject under review is the medical necessity for the inpatient substance abuse treatment.

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

The adult inpatient treatment of this patients substance use disorders did warrant the admission and the continued structure of an inpatient level setting. Withdraw symptoms were managed with tapering dosages of benzodiazepine and Suboxone requiring monitoring and as needed (prn) medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy.   The patient did require a safe and effective substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if treatment were to be attempted at a lower level of care. This answer and determination is also consistent with the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines, referenced below.