Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction.
Treatment: Substance Abuse Inpatient. 
The insurer denied: Inpatient substance abuse treatment.
The denial is: Upheld in whole.

The patient is a male self-referred and requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with use of one pint of liquor and two six-packs of beer together with daily use of up to $200 worth of crack cocaine and use of cannabis intermittently. He had a history of alcohol use beginning in adolescence with use of cocaine beginning in his late 20's. He reported twenty or more prior substance use disorder treatments with relapse and his treatment history included at least three rehabilitation treatments in the past without follow up or involvement in recovery groups. 

Mental status examination revealed mild symptoms of anxiety and reports of insomnia with no severe symptoms and fair insight and motivation for treatment. Speech was clear and thoughts were linear. There was no evidence for psychosis, perceptual disturbance, severe cognitive impairment or mania, and the patient denied suicidal ideation or aggressive impulses. 

The patient is unemployed and receives disability payments (SSI) and had limited social supports. He was homeless and had been living in a shelter or with friends. 

The patient was admitted on for inpatient substance abuse treatment and other medical services following the assessment for safety issues and medical clearance. He received vitamin replacement therapy, and other supportive measures including as needed (prn) Vistaril for insomnia and anxiety. The patient's hospital course progressed without incident. He was placed on a Librium taper over a five day time frame. The patient slept and received meals without complications. His gait was normal and there was no evidence for severe withdrawal symptoms. His monitoring occurred without incident throughout the inpatient stay. The patient had received counseling with recommendation for clinically appropriate aftercare including involvement with counseling and educational groups. He declined medication assisted treatment. He was discharged with completion of the detoxification treatment with immediate transfer for clinically appropriate aftercare and rehabilitation substance-related treatment. However, he left to address his disability status with plans to return for rehabilitation treatment. The subject under review is the medical necessity for the inpatient substance abuse treatment. 

The health plan's determination is upheld in whole. 

The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine, and a diagnosis of schizophrenia. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment. 

Thus, in summary, inpatient substance abuse treatment was not medically necessary in this case scenario. Any indicated treatment for substance use disorder in this case could have been provided, as clinically appropriate, at a lower level of care. 

This answer is consistent with established practice guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) Criteria, and is consistent with the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below.