Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male who presented to the emergency department and was admitted for detoxification and withdrawal management from alcohol and other substances of abuse. The patient was using alcohol on a continuous daily basis with up to three pints of vodka together with intermittent use of a benzodiazepine and cannabis. He had a longstanding history of alcohol use beginning in adolescence. He was tobacco dependent at one-half pack per day use.
The patient provided no history of withdrawal seizures or delirium tremens (DTs). His laboratory assessment revealed evidence of malnutrition and proteinuria. His vital signs were normal, and the patients Clinical Institute Withdrawal Assessment (CIWA) scale score was at 3 with anxiety and diaphoresis and dilated pupils. There was no evidence for use of other illicit drugs or other drugs of abuse. The patient has a history of gastroesophageal reflux disease (GERD) and tension headaches.
There was no psychiatric co-morbidity. The patient denied past psychiatric hospitalization or suicidal behavior. He was employed and domiciled and lived with family. There were no legal issues or trauma history in this case.
The patient was admitted for inpatient detoxification and medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and supportive measures.
The patient's hospital course progressed without incident. He was placed on a clonazepam taper with vitamin replacement therapy. The patient slept and received meals without complications. His gait was normal and there was no evidence for severe withdrawal symptoms; he remained anxious and complained of a mild headache. He was described as pleasant, cooperative, and calm with no severe symptoms such as perceptual disturbance, cognitive impairment, psychosis, aggressive impulses, or suicidal ideation. His monitoring occurred without incident throughout his inpatient stay and the patient was feeling better as the treatment proceeded.  The patient had received counseling with recommendation for clinically appropriate aftercare including involvement with self-help recovery groups.
He was discharged with completion of his detoxification treatment with recommendations for clinically appropriate substance use disorder treatment and aftercare.
At issue is the inpatient hospital admission for dates of service for medical necessity.
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
The patient in this case presented with continuous daily use of alcohol; he did not experience complications or present with co-occurring psychiatric disorder, abnormal findings on examination, or severe withdrawal symptoms. He scored a 3 on the CIWA scale for alcohol withdrawal. His risk for withdrawal complications including seizures and delirium tremens, were minimal considering his history, and he did not pose a safety risk that warranted the inpatient hospital admission. 
The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. 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 risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient hospital admission. This is consistent with established practice guidelines, scientific literature, and American Society of Addiction Medicine (ASAM) Criteria.
Thus, the inpatient hospital admission was not medically necessary.