Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Withdrawal - Alcohol Abuse
Treatment: Residential Treatment Center
The health plan denied the requested Residential Treatment Center as not medically necessary. 
The health plan's determination is upheld.

The patient is an adult female who presented with a request for detoxification treatment and withdrawal management of severe alcohol use disorder. The patient reported a relapse four months earlier drinking alcohol in large quantity on a daily basis with up to ten hard seltzers and varying amounts of wine. The patient was medically screened. The patient had no acute medical issues. Her blood alcohol level was at 0.253. She had psychiatric comorbidity with anxiety and depression treated by her primary care physician (or provider) (PCP) with Gabapentin and Lexapro.

The patient was admitted to residential level care, and was placed on a detoxification regimen with Librium and supportive measures with comfort medications, as well as vitamin and nicotine replacement therapy. The detoxification was uncomplicated with regard to withdrawal management in that she was noted to be in no apparent distress, and her appetite and sleep normalized. The patient received counseling and education from the staff. Her clinical course was uncomplicated with normal vital signs. She had mild withdrawal signs or symptoms with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 6, and she was stable and in no distress. She had resumed treatment with his home medications including Lexapro and Gabapentin, and as needed (prn) Trazodone for sleep and prn use of Propranolol, as well as medication assisted treatment with Naltrexone. The patient continued to do well with treatment with family support despite a strained family relationship, and she was discharged with clinically appropriate aftercare and immediate referral to outpatient rehabilitation substance use disorder treatment though she was uncertain about Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP) level services, and was not planning to attend 12-step meetings.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of Residential Treatment Center was not medically necessary for this patient.
The requested benefit of detoxification treatment and withdrawal management and other medical services could have been safely and effectively provided with alternate level services. 
There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted the continued residential level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate continued residential level treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from alcohol. The patient was considered to be motivated for detoxification treatment, and had access to substance use disorder services in the community. The denial determination reasonably indicated that an alternate level treatment was an appropriate alternative to continued residential level services and was in the best interest of the patient.
Thus, medical necessity is not met in this case for the requested benefit of the continued residential level services in keeping with prevailing standards of professional practice, and consistent with the ASAM (American Society of Addiction Medicine) Criteria and scientific literature, referenced below, as well as New York State OASAS (Office of Addiction Services and Supports) LOCADTR (Level of Care Determination) 3.0 Guidelines, referenced below. The requested continued residential level treatment for alcohol use disorder and co-occurring psychiatric disorders could have been effectively provided with an alternate level care, as the health plan asserts in the denial determination.