The patient presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) and stimulant (crack cocaine) class substances of abuse. The patient also has chronic lower back pain that resulted from an injury due to a gunshot wound. The patient reported a past history of severe withdrawal symptoms when attempting to curtail use, and had recently undergone a detoxification treatment approximately two months prior to presentation with relapse and resumption of use of heroin and crack cocaine The patient had only recently used cocaine, but had been using heroin since the age of 17 years with longstanding use and only the one prior treatment episode. The patient was using up to 9 bags of heroin and 1 gram of crack cocaine on a daily continuous basis. The health plan's determination is overturned.

The continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications, as noted in the clinical summary. The patient's history of opioid use and recent use of crack cocaine, limited psychosocial supports and psychosocial stressors within several domains including limited social supports, and risk for relapse in view of recent detoxification with relapse did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with chronic pain and addiction to multiple substances of abuse.
Thus, the patient did require a safe and effective detoxification treatment for the dates in question as it was foreseeable that the patient was unable to abstain from use of opioid or cocaine, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, the continued inpatient level care through discharge was warranted using the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.