Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Medially Supervised Inpatient Detoxification Admission.
The insurer denied the Medially Supervised Inpatient Detoxification Admission.
The denial is upheld.

The patient is an adult male who presented for detoxification services. The patient was using alcohol on a continuous daily basis with up of two pints of brandy together with a six-pack of 20-ounce beers and use of $20 worth of crack cocaine at a frequency of one to two (1-2) times per week, and two marijuana joints (cannabis) daily use. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with a Clinical Opiate Withdrawal Scale (COWS) scales score of nine and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of ten with sweats and anxiety, as well as urges to use. He had a positive drug screen for cocaine and cannabis consistent with history, and a blood alcohol level of zero. The patient has a history of multiple detoxification treatments including a recent discharge. He reported two prior attempts at rehabilitation treatment with "no clean time."

The patient was admitted for inpatient detoxification. The patient's hospital course progressed without incident. However, his blood pressure was elevated requiring use of clonidine. The patient slept and received meals. His monitoring occurred without incident, and he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare. He completed the detoxification protocol and was discharged with referral for further treatment as clinically appropriate including inpatient rehabilitation services and follow up with primary care.

No, the proposed treatment, Inpatient Admission was not medically necessary for this patient.
The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require 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, cocaine and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment, or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with past treatment, as noted. Thus, the inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with 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 and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (ASAM) Criteria, as referenced below.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive treatment setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment, or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or significant biomedical issues in this case that would have required inpatient level care. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts in the denial determination. In addition, the New York State NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.