Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient substance abuse treatment
The insurer denied the Inpatient substance abuse treatment.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male. He presented to the emergency department with a request for detoxification services. The patient reported using alcohol on a continuous daily basis with up of 1.5 pints of liquor together with a 12-pak of large size beer and with the use of cocaine with approximately $200 worth of crack cocaine per week. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with reports of nausea, vomiting, fatigue, chills and muscle cramps. He had a positive drug screen for cocaine and benzodiazepines consistent with history of cocaine use and recent detoxification with recent discharge from another facility the day prior to presentation. He had 24 treatment episodes for substance use disorder.

The patient has no history a psychiatric disorder or mental health treatment. Again, he had received multiple past substance use disorder treatments with relapse. 

The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. The patient had no acute general medical problems but was in treatment for hypertension with enalapril and gastritis with omeprazole, and he had a history of eczema and bronchial asthma with use of a rescue inhaler. He was tobacco dependent at two packs per day since adolescence. He was medically screened and admitted for inpatient level detoxification with plans for a five-day detoxification treatment episode with Librium, vitamin replacement therapy and comfort medications, as well as continuation of his medications to address hypertension and alcoholic gastritis.

On 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 thought disorder, cognitive impairment, mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. He denied past psychiatric hospitalization. He presented with anxiety/irritability and insomnia. He had fair control of his impulses. He reported somatic complaints or symptoms reflecting withdrawal, as noted and as well as anxiety and insomnia.

The patient is single, homeless and unemployed. There was no report of current legal issues or trauma history. He had limited social supports.
The patient was admitted for inpatient detoxification and withdrawal management. The patient's hospital course progressed without incident and with persistent symptoms of anxiety and reports of poor insight. His mild symptoms of withdrawal had resolved by day two of his inpatient stay. The patient slept and received meals. Again, 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. 

The patient completed the detoxification treatment and was discharged with referral for clinically appropriate aftercare, but declined further substance use disorder treatment or referral for rehabilitation treatment. Instead, he indicated that he would seek shelter from the Salvation Army.

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 and cocaine and general medical issues with hypertension, alcoholic gastritis, bronchial asthma and eczema. 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 treatment recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. 
The patient did display poor insight and had poor control of impulses, but he had a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, 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 OASAS LOCADTR 3.0 Criteria/Guidelines and with the scientific literature, and ASAM Criteria, as referenced below.