Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment 
The insurer denied the inpatient substance abuse treatment.
The denial is overturned. 

The patient is a adult male requesting detoxification treatment. He was admitted to acute inpatient level care in order to address substance use disorder with alcohol and sedative-hypnotic-anxiolytic (benzodiazepine) class substances, as well as past use of opioid, stimulant and cannabis class drugs of abuse. The patient had been using large quantities of alcohol daily together with misuse of Valium intermittently. He has no history of withdrawal seizures or delirium tremens. 

The patient has a history of psychiatric disorder with unspecified bipolar depressive disorder and posttraumatic stress disorder.

The patient presented with chronic co-morbid general medical conditions that included benign prostatic hypertrophy and hypogonadism with associated treatments. Laboratory assessments were unremarkable or normal with a drug screen consistent with history. He was tobacco dependent with one pack per day use since a young age.

The patient's evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with depressed mood and a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and the onset of alcohol withdrawal. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation and did not have perceptual disturbances. Insight was limited with impaired judgment and poor control of impulses. His onset of mild withdrawal symptoms included anxiety, insomnia, malaise, tremor, nausea, and rhinorrhea with normal blood pressure and pulse.

Yes, the Inpatient substance abuse treatment was medically necessary for this patient.

The requested Inpatient admission and continued treatment 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 alcohol on a daily continuous basis with intermittent use of Valium that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the inpatient stay. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. The patient's social environment was not conducive to detoxification in the context of co-occurring psychiatric disorders and psychosocial stressors-as indicated in the clinical summary.

Thus, the requested adult inpatient detoxification treatment and withdrawal management of this patient's alcohol use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn (as needed) medications including medication assisted treatment. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and co-occurring psychiatric disorders and general medical issues in this case 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 if the continued detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of the NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (Level of Care Determination) Tool that requires the patient in this scenario default to the higher level of care.