Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Treatment
The insurer denied the Inpatient Substance Abuse Treatment.
The determination is overturned.

The patient is a homeless male and was admitted to inpatient substance use treatment for the treatment of alcohol and cocaine use disorder. During admission, his provider stated that it was the patient's desire to obtain withdrawal management from alcohol as well as get help to stay away from cocaine. A Level of Care for Alcohol and Drug Treatment Referral (LOCADTR-3) had been used to determine the appropriate service level. According to this tool, he did not require the services because his vital signs were stable with a blood pressure of 144/78 and pulse of 94 beats per minute. There were only very mild withdrawal symptoms noted by his provider. There were no acute medical or mental health conditions and his condition did not require 24-hour-a-day nursing care and monitoring. His need for ongoing relapse prevention treatment of substance use symptoms could have been safely treated in a less restricted level of care such as rehabilitative services in a residential setting as recommended by LOCADTR-3 tool.
He was placed on a five day Librium protocol during his admission. He reported drinking two pints of liquor and 2 six packs of beer on a daily basis. He was also smoking crack cocaine one to two times per week. His blood alcohol level on admission was 0.133 and his toxicology came back positive for cocaine and benzodiazepines. However, he denies any recent use. He admitted to having blackouts and not feeling well at the time of his admission. Based on his presentation, the medical team felt that medical supervision was necessary. He has a history of more than 20 treatment episodes and he was unable to remain stable and drug-free on his own. He lacks a sober support network and he was in need of building better coping skills and identifying triggers/stressors. His goal was to complete detoxification services and step down to inpatient rehabilitation services. He successfully completed detoxification and did step down to rehab services in this facility.
A Clinical Institute Withdrawal Assessment (CIWA)-AR score was 12 and no acute detoxification symptoms were noted. His existing signs/symptoms include nausea, trouble sleeping, anxiety, and hot/cold sweats. On admission, his vital signs were 144/78 with pulse of 94. A detox Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was performed. Per this analysis, he was incapacitated by substance. He had no risk of physical harm or risk of severe withdrawal or complications or comorbidities. He had risk of moderate withdrawal. He had a lack of support for early abstinence, and therefore he was recommended inpatient medically supervised withdrawal treatment. Librium protocol was started for alcohol dependency detoxification and he was also given other comfort medications.
A progress note indicates that he safely completed detoxification and has accepted a referral. He has been observed following rules and regulations of the unit and he is not in need of mental health referral. He was stable upon discharge. He is still in need of coping skills, a recovery action plan and sober support network. At issue is the medical necessity of inpatient substance abuse treatment.
The requested health service/treatment of inpatient substance abuse treatment was medically necessary for this patient. As explained above, the patient's toxicology was positive for cocaine and benzodiazepine along with blood alcohol level of 0.131. He has no safe environment. He was at risk of developing severe withdrawal symptoms. Therefore, he was appropriately admitted to inpatient level of care and he received appropriate treatment with detox medication and monitoring of his withdrawal symptoms.
Per LOCATDR, it was noted that the patient had alcohol use disorder. He met criteria for tolerance and/or withdrawal. It was noted that he requires vital sign monitoring and requires medication management of withdrawal symptoms. He had no significant medical conditions or significant psychiatric disorders reported. No M 80 availability in the community was noted. No interpersonal or personal skills deficits were indicated. No available resources were endorsed during the interview. Therefore, LOCATDR recommendation was residential. However, several discrepancies were identified with the initial LOCATDR: the review of submitted documents revealed that at the time of assessment, the patient has a blood alcohol (BAL) level which is high (0.131) which could mask the patient's withdrawal symptoms. He was clearly having risk of withdrawal at the time of admission since he was able to tolerate higher amounts of alcohol. He had a significant history of alcohol use disorder with multiple previous trials of detoxes and treatments. He was reportedly homeless and had no active treatment, or social support which increase his risk. Additional to his alcohol use, his toxicology was positive with benzodiazepines which is another significant factor which could contribute/worsen his conditions and would complicate his detoxification and treatment. Individuals under the influence are generally poor historians, and therefore may not be able to provide reliable a history regarding past severe withdrawal seizures, such as seizures. Therefore, it was appropriate for this patient to be safely treated at the offered level of care.