Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient detoxification level of care
The insurer denied inpatient detoxification level of care.
The determination is overturned.


The patient was admitted, following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol and stimulant (cocaine) use disorders. The patient was using up to twelve 24 ounce beers daily together with $100-$200 worth of crack cocaine six days per week.

The patient was referred from an outpatient substance use treatment center due to his continued use of substances despite involvement in treatment. He presented with mild alcohol withdrawal at the time of admission. Withdrawal symptoms included tremor, insomnia, irritability and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 10. The patient has no history of a psychiatric disorder. He denied psychiatric hospitalization, or suicidal or self-harming behavior. He had an extensive history of substance-related treatment episodes including at least three detoxification treatment episodes. There were no acute medical issues or general medical concerns.
The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a five-day Librium taper, vitamin replacement therapy, fluid replacement, and medical monitoring; the patient was tobacco dependent and offered smoking cessation treatment and nicotine replacement. Following his first day of treatment, the patient began to participate in counseling and educational sessions. Vitamins were continued, as well as comfort medications with monitoring and assistance with daily activities. He was maintained on fall and seizure precautions, but had no history of withdrawal seizures or delirium tremens (complicated withdrawal). His demeanor improved as he underwent detoxification treatment, and he was social with peers. He participated in educational sessions and counseling during the remaining days with motivational interviewing with the goal of proceeding to rehabilitation treatment and/or accepting medication assisted treatment. The patient was discharged after completion of the detoxification protocol with plans/referral to start a rehabilitation treatment and with recommendations for involvement in 12-step recovery meetings.

The health plan documents, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's rationale for the denial of certification for coverage of the requested treatment were reviewed. The case records and case summary were reviewed. This review is a New York State mandated review, including the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.

The issue under review is the medical necessity of inpatient detoxification level of care.

Yes, the requested health service/treatment of inpatient detoxification level of care was medically necessary for this patient.

The patient presented with a diagnosis of severe alcohol and stimulant use disorder. The presenting clinical features and history and risk for withdrawal seizures and other psychosocial complications of alcohol and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario.

The adult inpatient treatment of this patient's substance disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with continued use of substances while receiving outpatient level substance-related services. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.

Medical necessity for the admission and the continued inpatient services is met in this case and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer is also consistent with the application of New York State OASAS LOCADTR 3.0 Criteria and Guidelines.