Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Substance abuse inpatient admission
The insurer denied the substance abuse inpatient admission.
The denial is overturned. 

The patient is male with a longstanding history of alcohol use disorder and subsequent use of benzodiazepines (Xanax and Klonopin). He was also receiving medication assisted treatment with Suboxone to treat opioid use disorder. The patient was admitted to inpatient level care for detoxification treatment following medical screening. He reported drinking multiple shots of vodka with a binge pattern of use together with daily use of a benzodiazepine with up to four milligrams (mg) (two sticks) of Xanax or Klonopin. He had frequent blackouts but denied history of withdrawal seizures or delirium tremens despite his longstanding use of alcohol and subsequent use of benzodiazepines in the context of severe symptoms of anxiety and depression. Additionally, the patient had an inadvertent overdose one month prior to admission. The patient was admitted for monitoring and detoxification and withdrawal management of severe alcohol and sedative-hypnotic-anxiolytic use disorder, and continued treatment for general medical conditions including chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and cardiac valve regurgitation, as well as a history of hepatitis B and C. 

The patient has a history of mental disorder and mental health treatment for anxiety and depression that resulted in job loss and disability and homelessness.

Mental status examination included evidence for poor coping skills with fair insight, judgment and impulse control. He presented as cooperative with good eye contact. Speech was clear with organized thought processing. There were no severe symptoms such as mania, psychosis, thought disorder, or perceptual disturbance, and, the patient denied suicidal ideation or aggressive impulses. He was anxious with withdrawal symptoms that included chills, sweats and restlessness with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of eight. 

The patient is single and lives with his girlfriend. He is college educated and unemployed and receiving disability support. There were no legal issues or trauma history in this case.

The patient was admitted to inpatient level care and placed on a detoxification regimen with vitamins replacement therapy and a detoxification protocol with benzodiazepine and medical monitoring with seizure and fall precautions. The patient gradually improved with better ability to perform basic activities of daily living by the day of discharge. The patient's metabolic state, laboratory functions, and vital signs normalized or remained normal. He received counseling and education together with peer support and group sessions offered within the therapeutic milieu. There were no general medical complications during the inpatient stay. He had continued use of Suboxone at eight milligrams (mg) twice daily in order to address the treatment of opioid use disorder. 

The patient was discharged with completion of the detoxification protocol with recommendations for continued substance-related treatment including outpatient services for the mental health follow up and involvement in 12-step recovery groups, and continued medication-assisted treatment for the opioid use disorder, as well as follow up for his general medical conditions.

The proposed treatment, Inpatient Admission for Detoxification and Withdrawal Management was medically necessary for this patient.

The requested benefit of detoxification treatment and withdrawal management and other medical services 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 together with benzodiazepines that did warrant inpatient level detoxification and withdrawal management and monitoring. The patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms. There was a history or frequent blackouts and a recent overdose reflecting the seriousness of his use of alcohol and benzodiazepines. 

Thus, the adult inpatient stay for detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments and a co-occurring psychiatric disorder do reflect the seriousness of the substance use disorder and co-occurring disorder with persistent anxiety and depression that served to trigger the patient's substance use. Again, the clinical features and treatment dimensions in this case do warrant and support the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of NY (New York) State State Office of Addiction Services and Supports (OASAS) Level of Care Determination (LOCADTR) 3.0 Criteria/Guidelines, referenced below. 

The requested benefit of Inpatient Admission for Detoxification and Withdrawal Management is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The substance abuse detoxification and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including American Society of Addiction Medicine (ASAM) Criteria and the application of NY State Office of Addiction Services and Supports (OASAS) Level of Care Determination (LOCADTR) 3.0 Criteria/Guidelines, referenced below.