Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance/Alcohol Abuse/Detoxification
Treatment: Inpatient Hospital
The health plan denied the inpatient stay. 
The health plan's determination is overturned.

The patient  presented to the emergency department with a request for detoxification treatment prompted by health concerns, psychosocial stress, impairment of functioning and complaints related to alcohol withdrawal. The patient was medically screened and admitted to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol use disorder. The patient reported daily use of alcohol with up to one gallon of vodka per day. He had multiple past treatment episodes including rehabilitation services and detoxification treatments with relapses and inability to abstain due to intense craving and co-occurring psychiatric disorder and severe psychosocial stressors that were triggering his use. The progression of the alcohol use disorder had occurred following 15 years of sobriety with a relapse. Additionally, he had a history of cannabis use and opioid use disorder and was participating in a Methadone maintenance treatment program (MMTP) with a dose of 30 mg daily. The patient has a history of co-occurring major depressive disorder treated with Sertraline and Olanzapine.

Mood was dysphoric with anxiety and irritability. His insight was limited and judgment impaired. Somatic complaints included the insomnia and gastrointestinal complaints and other alcohol withdrawal symptoms.

The patient was admitted to inpatient level care and placed on a detoxification regimen with a five-day Librium taper, as needed (prn) dosing of Ativan and Benadryl, vitamin and nicotine replacement therapy, electrolyte and fluid replacement, and medical monitoring. Following his first two days of treatment, the patient began to feel better. The patient requested an against medical advice discharge and was discharged accordingly with recommendations for clinically appropriate aftercare. 

The requested inpatient admission and continued stay for detoxification treatment, withdrawal management, stabilization and other medical services is medically necessary for this patient.
The patient in this case presented with a diagnosis of severe alcohol use disorder with symptoms of withdrawal. He had co-occurring major depressive disorder that was related to and triggering his alcohol use disorder, as well as severe psychosocial stressors and severe pulmonary disease associated with low weight.

The presenting clinical features that included abnormal EKG (electrocardiogram) and laboratory assessment, and risk for withdrawal seizures and other psychosocial complications of alcohol use disorder. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively or safely provided at a lower level of care in this case scenario.

The proposed inpatient admission and continued stay for detoxification treatment, withdrawal management, stabilization and other medical services could not have been safely and effectively provided at an alternative level of care. This patient's substance use disorders did require admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with withdrawal symptoms and complications of the alcohol use disorder with large quantity of alcohol being consumed daily while participating in a Methadone program for opioid use disorder. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy. It was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at an alternative level of care.