Appeal type: Medical necessity
Decision: Upheld

Alcohol abuse/Addiction
Substance abuse: inpatient

The patient is an adult who presented to the emergency department with a request for detoxification services. The patient was using alcohol on a continuous daily basis with two to four pints of liquor together with intermittent use of cocaine with approximately $200 worth, as well as cannabis (marijuana and K2/Spice) and heroin with 10-20 bags on a frequent basis. Patient presented with a blood alcohol level of zero and mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 3 and Clinical Opiate Withdrawal Scale (COWS) scale score of 2 reflecting minimal or light withdrawal symptoms. Patient has a history of schizoaffective disorder, bipolar type with last treatment for this disorder five years prior to presentation. Patient had received multiple past substance use disorder treatments including at least two detoxification treatment episodes and four substance-related rehabilitation treatments with one residential and three outpatient treatment episodes. 

The patient has a history of past psychiatric hospitalization for the mood and psychotic disorder, as well as a history of overdose. Patient was receiving no current treatment for a psychiatric disorder. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms, and did report blackouts. Patient was tobacco dependent. Patient was medically screened and admitted for inpatient level detoxification with plans for a four day detoxification treatment episode with Librium and methadone tapers, vitamin replacement therapy and comfort medications, as well as resumption/continuation of  usual psychotropic medication, low dose risperidone. Laboratory assessment and electrocardiogram (EKG) were unremarkable and drug screen was positive for cocaine and opioids consistent with history. Mental Status Examination: The patient was cooperative with good eye contact.  Speech was clear and thought production was linear and logical. There were no severe symptoms on mental status examination such as cognitive impairment, severe mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. Patient presented with anxiety/irritability dysphoria and withdrawal symptoms that included nausea and gastrointestinal upset, chills, aches, rhinorrhea, piloerection and sweats. Patient also had limited insight, impaired judgment and poor to fair control of  impulses. Patient reported decreased appetite and sleep disturbance and fatigue with malaise. Patient was compliant with treatment, and progress notes indicate that social with peers and had no apparent distress during stay. Patient tolerated the taper of methadone and Librium and was placed on Campral with discontinuation of the risperidone. Patient was discharged upon completion of the detoxification treatment and was advised to attend 12-step recovery groups and referred to rehabilitation substance use disorder treatment. Health plan's determination is upheld in whole. 

Detoxification treatment could have been safely and effectively provided with lower level services. The patient in this case was using alcohol on a continuous daily basis with intermittent use of cocaine and cannabis and frequent or near daily use of heroin. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services, and the patient's schizoaffective disorder was stable and was not being actively treated. Moreover, the withdrawal symptoms were not reported to be severe, and were mild or light, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment, and had access to substance use disorder services in the community.