Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizoaffective Disorder
Treatment Inpatient Substance Abuse Services
The insurer denied Inpatient Substance Abuse Services.
The determination is upheld.

The patient was admitted to inpatient level services for detoxification of alcohol and stimulant class substances of abuse. The patient had been using up to one pint of liquor plus beer on a continuous daily basis, as well as two grams of crack cocaine and two grams of cocaine with intranasal administration (snorting). He reported no past history of withdrawal seizures or delirium tremens. His self-referral was prompted by his desire to stop using these substances and get his life in order. He presented with mild to moderate symptoms of withdrawal that included tremor, nausea, sweats, anxiety and irritability. He had longstanding use of substances since adolescence. The patient had received multiple detoxification treatments with over fifty treatment episodes and many treatment episodes occurring with back-to-back admissions. He had also participated in at least five rehabilitation programs in the recent past.
The patient has a history of mood and psychotic disorders best characterized as schizoaffective disorder, bipolar type. He receives outpatient mental health treatment with Seroquel and trazodone. He was hospitalized most recently and has a history of self-harming behavior (cutting self) when intoxicated. He denied recent self-harm or suicidal behavior. His adherence to his medication was questionable due to his ongoing substance use.
There were no acute general medical issues in this case. Laboratory assessment was unremarkable or normal. A drug screen was positive for cocaine and benzodiazepine consistent with his history of cocaine use and recent detoxification treatment. Chronic medical conditions included hypertension, type II diabetes mellitus and dyslipidemia in the context of tobacco dependence at one pack per day with 35 pack years of use.
His mental status examination was free of severe symptoms such as thought disorganization, severe mood disturbance, psychosis, cognitive impairment or perceptual disturbance. He was calm and cooperative, though guarded, with anxiety and irritability. He denied suicidal ideation or aggressive impulses. His insight and judgment were limited and impaired. The patient was deemed to be motivated to enter detoxification treatment.
The patient is single and disabled with Supplemental Security Income (SSI) supplements. He was homeless and living on the street in the subway station. There were no legal issues or trauma history in this case.
The patient was admitted and placed on his usual medications including atorvastatin, lisinopril, metformin and omeprazole together with vitamin replacement therapy and comfort medications. He was continued with Seroquel and trazodone to address his mental disorder. The detoxification treatment was uncomplicated with regard to withdrawal management with the use of Librium. He was calm, compliant and cooperative with the treatment plan. The patient was social with peers and slept and ate well. He received counseling and education from the staff. His clinical course was benign with normal vital signs, improved insight, and ongoing work with case management with regard to discharge planning. The patient was discharged with recommendations for clinically appropriate aftercare including continued treatment for his mental health disorder and recommendations for involvement with peer-supported recovery groups and a plan to return for rehabilitation services.

No, the requested health service/treatment of inpatient substance abuse services is not medically necessary for this patient. Care could have been safely and effectively provided with lower level services. The patient in this case was using alcohol on a continuous daily basis, as well as the use of cocaine and crack cocaine in large quantities. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, 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 (current suicidal behavior or self-harm), and the patient has 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. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification treatment in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, referenced below; and this answer is in keeping with NY State OASAS LOCADTR 3.0 Criteria/Guidelines, also referenced below.