Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Substance abuse/Addiction
Secondary Diagnosis:  Alcohol abuse/Addiction
Treatment:  Substance abuse Inpatient

The patient is an adult self-referred and requesting detoxification from alcohol.  The patient was using alcohol on a continuous daily basis with up to one pint of liquor and three times 24 ounces of beer together with crack cocaine intermittently.  Patient had a history of alcohol use with the subsequent use of cocaine.  There is no report of sustained periods of abstinence.  The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms; vital signs at the time of presentation revealed elevated blood pressure, and the Clinical Institute Withdrawal Assessment (CIWA) scale score was 11/67 with mild symptoms including sweats, mild tremor, irritability and anxiety/agitation.  The urine drug screen was consistent with history and laboratory assessment was normal or unremarkable.  There was no reported use of other illicit drugs or other drugs of abuse.  The patient was tobacco dependent at one pack per day use.  There were no acute general medical issues in this case.  The patient has chronic medical conditions including hypertension, dyslipidemia and diabetes mellitus treated with hydrochlorothiazide (HCTZ), amlodipine, Lisinopril, and Lipitor. Patient was medically screened and cleared for admission to detoxification treatment.  The patient has a history of multiple detoxification treatment episodes with relapse occurring sometime during the eleven days prior to presentation.  There is no history of rehabilitation substance use disorder treatments.  There was no psychiatric comorbidity diagnosed in this case.  Mental status examination revealed mild symptoms of anxiety and reports of insomnia with no severe symptoms and fair insight and motivation for treatment.  The patient was admitted and received vitamin replacement therapy, and other supportive measures including amitriptyline for insomnia and anxiety.  The patient's hospital course progressed without incident.  Patient was placed on a Librium taper over a five day time frame.  The patient slept and received meals without complications.  The gait was normal or steady, and there was no evidence of severe withdrawal symptoms during the stay.  Monitoring occurred without incident throughout the inpatient stay.  The patient was social with peers and in no distress.  The patient had received counseling with recommendation for clinically appropriate aftercare including continued involvement with counseling and educational groups.  Patient was discharged with completion of the detoxification treatment with recommendations for clinically appropriate aftercare and rehabilitation substance-related treatment, as well as primary care of general medical conditions.  The health plan's determination of medical necessity is upheld in whole.  The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care.  The clinical features and indicated treatment dimensions of this patient's alcohol use disorder and other substance use disorder did not require or warrant the structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status, despite having a history of ongoing substance use disorder with alcohol and ongoing treatment for an unspecified depressive disorder.  Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and she did not show evidence for suicidal or aggressive behavior, risk or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.  Risk for withdrawal complications including seizures and delirium tremens were minimal, considering  history and recent detoxification treatment, and the patient did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested.