Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient Stay.

The insurer denied the Inpatient Stay.  The determination is overturned.

The patient was transferred from another facility and evaluated in the emergency department and admitted to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder and cannabis and opioid use disorders.  The patient has a past history of detoxification/substance use disorder treatments with most recent  with relapse using one pint of vodka per day.  He was also receiving medication treatment with Suboxone for opioid use disorder.  He had no history of withdrawal seizures or delirium tremens.  The patient presented with general medical issues that included withdrawal symptoms and chronic conditions, including hypertension in the context of tobacco dependence.  Additionally, the patient has a history of bipolar mood disorder and attention deficit hyperactivity disorder (ADHD) treated with Depakote, Effexor extended release (XR), Zyprexa and Adderall.  The patient's self-referral was prompted by health concerns, the desire to take better care of himself, and severe psychosocial stressors.

The patient was admitted following medical screening and stabilization in the emergency department, and he was placed on a detoxification regimen with the use of Ativan, vitamin and nicotine replacement, and medical monitoring.  Vitamins and nicotine replacement were continued, as well as comfort medications, monitoring with seizure precautions, and assistance with daily activities.  Withdrawal symptoms were mild with a Clinical Institute Withdrawal Assessment (CIWA) ranging from 9 to 11, including abdominal cramps and nausea, tremor, sweats, anxiety, motor agitation and restlessness.  Mental status revealed no severe symptoms, including no suicidal ideation or aggressive impulses, no overt mania, depression, psychosis, perceptual disturbance or cognitive impairment.  He did display anxiety and reported fatigue and low energy with diminished concentration and withdrawal symptoms as noted.

The patient remained functional throughout the hospital course and was better able to perform basic activities of daily living with the diminution of his withdrawal symptoms.  He participated in counseling sessions, educational sessions and group meetings with peers.  Thus, he was provided education and counseling with regard to subsequent care and met with the case manager to address stressors that included housing, primary support, financial, occupational and social environment domains.  His psychotropic medications were continued together with metoprolol for hypertension.  Vital signs, laboratory assessments and electrocardiogram (EKG) were normal or unremarkable.  
The patient completed the detoxification treatment and was discharged by which time his CIWA had decreased to a 2 with minimal alcohol withdrawal symptoms.  He tolerated the resumption of his psychotropic medications, though he was not given Adderall, as this was not on the hospital formulary.  The patient was discharged with recommendations for clinically appropriate aftercare to include outpatient substance use disorder treatment with continued involvement in medication assisted treatment for the opioid use disorder and mental health services, primary care for his general medical issues, and recommendation for involvement in 12-step recovery groups with the obtainment of a sponsor.  He was discharged with plans for smoking cessation and his usual medications.

The health plan documents, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's rationale for the denial of certification for coverage of the requested treatment were reviewed.  The case records and case summary were reviewed.  This review is a New York State mandated review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.  

The issue under review is the medical necessity for inpatient admission for detoxification, withdrawal management and stabilization for dates of service.  The requested health service/treatment of inpatient services/stay for detoxification, withdrawal management and stabilization is medically necessary for this patient.  The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder, and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care.  The adult inpatient treatment of this patient's substance use disorders and co-occurring psychiatric disorders and severe psychosocial stressors did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the extent and severity of the substance use disorder, and the need to resume treatment for the bipolar mood disorder, as well as medication assisted treatment with Suboxone.  Withdrawal symptoms were managed with as-needed dosages of benzodiazepine requiring monitoring, as well as comfort medications, and replacement of vitamins and nicotine.  The patient's history of substance use disorder (frequency and quantity) and co-morbidities do reflect the seriousness of this case, such that an inpatient setting was necessary for a safe and effective detoxification treatment episode.  The patient did warrant the requested inpatient level detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from alcohol and would have continued to be non-compliant with his outpatient treatments if detoxification were to have been attempted at a lower level of care.  Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and ASAM Criteria, referenced below.  This answer is also consistent with the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below, which supports the decision for this patient receive substance use disorder treatment and services at the inpatient level of care for the duration of treatment provided in this case.