Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse/addiction
Treatment: Inpatient hospital stay
Issue: Medical necessity of the inpatient hospital stay.
The health plan's determination is overturned in whole. 

The patient was brought to the emergency department by family after a fall. Patient presented in an intoxicated state and was agitated and combative with general medical complications. On initial evaluation blood alcohol level was 500 with pancytopenia, elevated liver functions and a metabolic acidosis (lactic acidosis). Additional testing revealed low blood pressure with tachycardia and sinus rhythm on electrocardiogram (EKG). A computed tomography (CT) scan of the head and C-spine, ultrasound of the liver, and a Chest X-Ray were obtained with evidence for hepatic steatorrhea and suspected pneumonia. Patient received fluid and electrolyte replacement and other supportive measures with stabilization and admission to acute inpatient level care.
The patient has a longstanding history of alcohol use with recent rehabilitation services  with outpatient follow up care and relapse. Psychiatric evaluation revealed no evidence for co-occurring psychiatric disorder. The patient had presented with alcohol intoxication and onset of withdrawal at the time of admission including gastrointestinal upset, tremors, diaphoresis, agitation, and anxiety. Patient was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol with use of Librium and Valium, as well as as needed (prn) Haldol and Ativan for acute agitation. Patient received vitamin replacement therapy including iron supplements for anemia. Patient was monitored with seizure and fall precautions, as well as receiving counseling, education and support from staff and family with whom the patient lived. Case management (social work) services worked with the patient and family to develop a discharge plan. 

The acute inpatient treatment of this patient's substance use disorder and medical complications did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders, and the presentation with several co-morbid medical complications of the alcohol use disorder. Withdrawal symptoms were managed and averted with a CIWA protocol and prudent dosages of benzodiazepine requiring monitoring, as well as comfort medications and vitamin replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was not reasonable that the patient would have been safe to receive treatment at a lower level of care. This answer is consistent with prevailing standards of medical practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria and with New York State instruction concerning medical necessity reviews including the application of 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 that indicated the necessity and appropriateness of the inpatient level treatment in this case.