Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder. 
Treatment: Medically Supervised Inpatient Detoxification. 

The insurer denied: Medically Supervised Inpatient Detoxification. 
The denial is overturned. 

The patient is an adult male who presented for detoxification and withdrawal management. The patient has a history of severe substance use disorders beginning in early adolescence escalating to daily use of alcohol and stimulant (crack cocaine) 
and frequent use of cannabis (marijuana) class substances of abuse. He has a long history of substance use with only one prior treatment episode with relapse and no sobriety. The patient was unemployed with limited family support, and homeless living in a shelter in a drug infested neighborhood; he reported severe psychosocial stressors within the primary support, social environment, occupational and housing domains. The patient displayed limited insight and impaired judgment due to the addictions. He demonstrated symptoms of anxiety and insomnia related to the alcohol and cocaine withdrawal. He received tapering dosages of Librium and replacement of vitamins, as well as nicotine replacement for tobacco dependence with the availability of counseling and comfort medications and as needed (PRN) medications prescribed for pain, anxiety, and insomnia that included trazodone. During the last two days of his treatment, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment. Arrangements were being made for a direct referral or step down to rehabilitation substance use disorder treatment. He was discharged after completion of the detoxification protocol with direct transfer for rehabilitation services. The health plan denied coverage for the requested services on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that the patient could have been provided services with lower-level care such as residential treatment. 

The requested health service/treatment of admission and continued stay at the inpatient detoxification facility was medically necessary for this patient. 

The requested benefit of inpatient detoxification 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 large quantities of alcohol on a daily continuous basis together with cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) 
Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the appropriate 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-referenced below.