Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Admission
The insurer denied the Inpatient Detoxification Admission
The denial is overturned

The patient is an adult male. He presented to an emergency department with request for detoxification treatment in the context of severe alcohol use. The patient has a history of severe substance use disorder with daily use of alcohol, Xanax and cannabis (marijuana). He was using up to three pints of vodka and six 16-ounce beers, one marijuana blunt, and one bar of Xanax daily. He has a history of prior detoxification treatment episodes with relapses and no recent sober time. His last detoxification treatment was approximately a few months earlier.

At the time of presentation to the emergency department, the patient reported functional decline as the substance use/disease had progressed. The patient provided no past history of withdrawal seizures or delirium tremens, but did report severe alcohol withdrawal symptoms in the past. He was screened and admitted for inpatient level care with plans for withdrawal management and detoxification and stabilization with a 5-day Librium protocol with CIWA (clinical institute withdrawal assessment) monitoring and supportive measures.

The medical screening had revealed evidence for elevated liver functions and a drug screen that was positive for THC (tetrahydrocannabinol), consistent with history. The patient's examination revealed withdrawal symptoms including diarrhea, sweats, tremors and chills together with anxiety and irritability with a CIWA (clinical institute withdrawal assessment) scale score in the mild range at 8-9 and a BAL (blood alcohol level) of 0.014 reflecting recent alcohol consumption. Vital signs were normal and laboratory assessment was normal or unremarkable other than the elevated AST (aspartate aminotransferase). Chronic conditions included hypertension, hyperlipidemia, GERD (gastroesophageal reflux disease), asthma, coronary heart disease and history of stroke. He was tobacco dependent at one pack per day. Medications included ASA (aspirin), amlodipine, atorvastatin, Depakote and albuterol inhaler that were continued.

The patient's hospital course progressed without incident. Vital signs remained normal. The patient reported mild nausea, anxiety, restlessness and irritability with persistently mild symptoms of withdrawal that diminished throughout her brief hospital course. He quickly stabilized and arrangements were being made for a referral to rehabilitation substance use disorder treatment and follow up. He completed the protocol and was discharge with recommendations for continuing his prescribed medications and involvement with self-help groups for support of a recovery, as well as recommendations for clinically appropriate aftercare with immediate transfer for inpatient rehabilitation treatment and services.

The health plan denied coverage for the requested services on the basis of New State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria indicating that the patient could have been sufficiently managed with lower-level care. The denial determination indicated that the withdrawal symptoms were mild, that the patient had no general medical or psychiatric symptoms requiring inpatient level care, and, that the patient had no history of complicated withdrawal and had access to support.

Yes, the Inpatient Detoxification Admission for detoxification treatment and withdrawal management and stabilization with monitoring and other medical services was medically necessary for this patient in keeping New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria and prevailing standards of medical practice.
The requested inpatient admission for detoxification treatment and withdrawal management and monitoring and other medical services 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 large quantities of alcohol with daily use, and two other drugs of abuse (marijuana and Xanax) with a presentation and history that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.

Inpatient hospital level care with detoxification, as necessary, and other treatments could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided in the emergency department and continued at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms and maintaining abstinence which were being effectively addressed with inpatient level monitoring with a Librium protocol and supportive measures. The patient had associated clinical features that included lack of sober supports and functional impairments with unemployment and serious general medical complications of the alcohol use disorder-contrary to the denial determination.

Thus, the appeal did appropriately indicate the necessity for the adult inpatient stay and detoxification treatment of this patient's substance use disorders that did warrant the hospital admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management and stabilization, as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Moreover, the stage of change was contemplative at best and the patient's lack of awareness or insight regarding the severe alcohol use disorder and risk for medical complications.

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, New York State instruction for medical necessity reviews including the appropriate application of NY (New York) OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria-referenced below. The health plan's denial on the basis of New York LOCADTR (level of care for alcohol and drug treatment referral) Criteria is not reasonable and attempting detoxification and other treatment in the emergency department or with lower-level treatment is not in the best interest of the patient or safe in this case scenario.

No, the health plan, in its determination of medical necessity, did not act reasonably with sound medical judgment and in the best interest of the patient.
The health plan's denial on the basis of NY (New York) State LOCADTR (level of care for alcohol and drug treatment referral) Criteria is not reasonable, and attempting appropriate treatment with lower-level services, as the health plan recommended, is not in the best interest of the patient, or safe in this case scenario. The requested Inpatient Hospital detoxification treatment and withdrawal management and monitoring and other medical services is clinically appropriate, medically necessary and warranted, and therefore should be covered in this case scenario.