Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (crack cocaine), and cannabis (marijuana) class substances of abuse. He has a history of prior substance use disorder treatment including detoxification treatment with relapse. The patient was using large quantities of alcohol on a continuous daily basis together with 16 grams of crack cocaine and intermittent and occasional use of heroin with intranasal administration.
At the time of presentation, the patient was requesting referral for rehabilitation substance use disorder treatment. He denied current legal issues or other external factors prompting his presentation for treatment. He was homeless and unemployed and reported severe psychosocial stressors within the primary support, social environment, occupational and housing domains. The patient reported functional decline as the substance abuse/disease had progressed which prompted his self-referral for detoxification treatment and request for rehabilitation services.
The patient provided a past history of withdrawal seizures and severe alcohol withdrawal symptoms. He was medically screened and admitted for inpatient level detoxification with plans for a four day detoxification treatment with Librium and supportive measures. Withdrawal symptoms and signs included tremor, nausea and vomiting, diaphoresis, malaise and fatigue, anxiety, and irritability, as well as insomnia. A drug screen was consistent with his history, but was positive for cannabis as well as cocaine. The patient has a history of psychiatric disorders (schizophrenia and/or bipolar disorder and anxiety disorder) and treatment including inpatient psychiatric hospitalization, but no history of overdose or suicidal or self harming behaviors.
There were no acute medical issues in this case other than the alcohol withdrawal, but the patient was medically ill with type II diabetes mellitus and chronic leg pain and dysplipidemia, as well as peripheral neuropathy. The patient was tobacco dependent.
The health plan's determination is overturned.
The patient was using large quantities of alcohol on a daily continuous basis together with other substances of abuse that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, nausea and vomiting, diaphoresis and malaise, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and comfort medications and with supportive measures that included seizure precautions in a patient with seizure history. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses.
Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patients history of substance abuse (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 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.