Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male requesting detoxification treatment and admitted to acute inpatient level care to address substance use disorder with alcohol, cannabis, and PCP class drugs of abuse. The patient had been using up to one pint of liquor daily plus beer and up to four marijuana blunts per day together with an unspecified quantity of PCP. He had a history of prior detoxification and substance use disorder treatments with relapses. His self-referral for treatment was prompted by multiple stressors including housing, primary support, social environment and other psychosocial domains.

The patient is single with unemployment and homeless and living with his sister. He did not report trauma or abuse history or legal issues. He had limited social supports from family.

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and mild to moderate symptoms or alcohol withdrawal. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation. Insight was limited with impaired judgment and fair control of impulses. His onset of withdrawal symptoms included anxiety, irritability, insomnia, agitation, nausea, sweats, tremor and headaches with a CIWA (Clinical Institute Withdrawal Assessment) scale score of 12.

The patient engaged with detoxification treatment; he was generally cooperative with the tapering dosages of Librium. Withdrawal symptoms remained mild, but persisted with mild tremor, anxiety and insomnia requiring prn medications and monitoring. 

The patient was discharged with plans for immediate outpatient level care and continued mental health and primary care referral.

Yes, the proposed treatment, Inpatient substance abuse treatment is medically necessary for this patient.

The requested Inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using alcohol on a daily continuous basis with use of other substances of abuse, including PCP and Cannabis, that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient had a positive drug screen that included PCP. He had moderate and persistent withdrawal symptoms, and, the patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and only fair control of impulses including a history of relapses with recent treatments.

Thus, this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn medications and continued treatment of the co-occurring psychiatric disorder. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and, in keeping with New York State instruction for medical necessity reviews including the appropriate application of the NY State OASAS LOCADTR Tool that requires the patient in this scenario default to the higher level of care.