Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He was admitted to a medically monitored high intensity inpatient detoxification level of care. He was noted to have been diagnosed with substance use disorders including alcohol, cocaine, cannabis and opioids. The patient was reported to have been admitted for detoxification from substances including alcohol, cannabis and opioids. He was noted to have a medical history significant for insomnia, hypertension and gastroesophageal reflux disease. The patient was also reported to have been diagnosed with schizophrenia. Other diagnoses indicated include bipolar disorder and anxiety disorder.

The patient was reported to have started using alcohol as an adolescent. He was reported to have been drinking several times each week for approximately two decades. He was last reported to have used alcohol earlier in the month of admission. The patient was reported to have started using heroin a few years prior. He was reported to have been abusing 5-12 bags of inhaled heroin daily for the past several years. The patient was last reported to have abused heroin on the day prior to admission. The patient was reported to have started abusing crack cocaine as an adolescent. He was reported to have been using between $ (dollars) 30-40 of crack cocaine per day for approximately two decades. He was last reported to have abused cocaine the day before admission. The patient was also reported to have a history of abusing cannabis and nicotine.

The patient was reported to have a significant history of substance abuse treatment in the past including multiple admissions to inpatient detoxification level of care. Most recently, the patient was reported to have been admitted to an inpatient detoxification level of care. There was no indication that the patient had any significant history of severe withdrawal in the past, including withdrawal seizures, hallucinations, or delirium tremens. The patient was reported to have been homeless at the time of his admission. He was reported to have been receiving Social Security income.

There was no indication that the patient had any significant ongoing behavioral health symptoms that required acute inpatient hospitalization. The patient was not reported to have any suicidal or homicidal ideations with plans or intent. There was no indication of the patient was at imminent risk of harm to himself or others. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient had no significant ongoing medical problems that required hospital-based interventions. He was not reported to have any functional impairments including activities of daily living and self-care that represented a change from his baseline. He was not reported to have had any significant adverse effects from any prescribed psychotropic medications. He was noted to have been discharged from the inpatient detoxification level of care against medical advice.

No, the Inpatient Detoxification Admission was not medically necessary.
Based on current peer-reviewed, evidence-based medical literature, the requested service (medically monitored, high intensity, substance abuse inpatient detoxification level of care) was not found to be medically necessary. The clinical information reviewed does not indicate that the requested service was the least restrictive setting that is medically necessary or that would be successful in treating the patient's symptoms (1-17).

Clinical documentation reviewed does not indicate that the patient had any significant ongoing withdrawal symptoms from substances at the time of his admission. There was no indication of the patient had any significant symptoms that required 24-hour medical and nursing care (1-4). The patient was not reported to have any significant unstable vital signs are of normal biochemical parameters. There was no indication that the patient had any significant physiological withdrawal symptoms as indicated by elevated scores on standardized withdrawal rating scale such as Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA) or Clinical Opiate Withdrawal Scale (COWS) (8-17). The patient was noted to have scored 10 on the CIWA (Clinical Institute Withdrawal Assessment) and 9 on the COWS (Clinical Opiate Withdrawal Scale) indicating minimal ongoing withdrawal symptoms.

There was no indication that the patient had any significant ongoing behavioral health symptoms that required acute inpatient hospitalization. The patient was not reported to have any suicidal or homicidal ideations with plans or intent. There was no indication of the patient was at imminent risk of harm to himself or others. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission.

The patient had no significant ongoing medical problems that required hospital-based interventions. He was not reported to have any functional impairments including activities of daily living and self-care that represented a change from his baseline. He was not reported to have had any significant adverse effects from any prescribed psychotropic medications. There was no indication of the patient had any significant barriers to treatment in the community. The patient had been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, based on current peer-reviewed, evidence-based medical literature, the requested substance abuse inpatient detoxification level of care was not found to be medically necessary or appropriate for the patient.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Clinical documentation reviewed does not indicate that the patient had any significant ongoing withdrawal symptoms that required 24-hour structured setting with medical and nursing care for treatment. There was no indication that the patient had any unstable vital signs or abnormal biochemical parameters. There was no indication that the patient had any significant physiological withdrawal symptoms as indicated by elevated scores on standardized withdrawal rating scales. There was no indication of the patient had any significant ongoing medical conditions that required interventions or monitoring. The patient was not reported to have any significant ongoing behavioral health symptoms that required acute inpatient hospitalization. He was not noted to be at imminent risk of harm to himself or others. There was no indication of the patient had any significant ongoing symptoms of psychosis or mania. Clinical information reviewed does not indicate that the patient had any significant functional impairments during activities of daily living or self-care that represented a change from his baseline. The patient had been treated safely and effectively in a less restrictive setting in lower level of care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient.