Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Mental Health: Inpatient. 

The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is an adult male self-referred and requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with use of two pints of liquor and beer together with daily use of one to two bags of heroin with intranasal administration, and, up to $40 worth of cocaine and two joints of cannabis (marijuana) use intermittently. He had a history of alcohol and marijuana and opioid use beginning in early adolescence with use of cocaine beginning in early adulthood. He reported limited prior substance use disorder/detoxification treatment. His treatment history included no rehabilitation treatments or involvement in self-help recovery groups. However, he was participating in a Methadone Maintenance Treatment Program (MMTP) with 110 mg (milligrams) of Methadone daily and other outpatient services. His referral for detoxification treatment was prompted by positive drug screens and mandatory requirement for treatment by the MMTP. 

The patient provided no history of withdrawal seizures, delirium tremens, blackouts, or severe alcohol withdrawal symptoms; vital signs showed a slightly elevated blood pressure, and the Clinical Institute Withdrawal Assessment (CIWA) scale score was not provided; he presented with mild symptoms including anxiety, irritability, and a report of insomnia. The urine drug screen was positive for cocaine and tetrahydrocannabinol (THC) and opiates including Methadone, consistent with history. There was no reported use of other illicit drugs or other drugs of abuse. There were no general medical issues in this case except for diabetes managed with monitoring and sliding scale insulin. He was medically screened and cleared for admission to detoxification with laboratory assessments and a chest X-Ray that were unremarkable. 

There was psychiatric comorbidity diagnosed in this case best characterized as bipolar disorder treated with Depakote and as needed (prn) use of Trazodone. He had a prior history of inpatient mental health stay with suicidal ideation/behavior. There was also history of a Heroin overdose. He was not taking his psychotropic medications due to the substance use. 

Mental status examination revealed mild symptoms of anxiety and reports of insomnia with no severe symptoms and fair insight and motivation for treatment. Speech was clear and thoughts were linear. There was no evidence for psychosis, perceptual disturbance, severe cognitive impairment or mania, and the patient denied suicidal ideation or aggressive impulses. 

The patient is unemployed and domiciled with limited social supports. There were no current legal issues, but trauma history with sexual abuse in childhood. He reported 27 years of incarceration with no current probation or parole status. 

The health plan's determination of medical necessity is upheld, in whole. 

No, the requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could have been safely provided at an alternate level of care in this case scenario. 

The patient in this case presented with continuous daily use of alcohol and Heroin while on MMTP, as well as intermittent use of cocaine and cannabis; he did not experience complications or present with severe symptoms of a co-occurring psychiatric disorder/depressive disorder, or abnormal findings on examination, or severe withdrawal symptoms. His risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and he did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested.