Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult male who presented for detoxification services. The patient was using alcohol on a continuous daily basis and using ten dollars worth of marijuana (cannabis) daily. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of five with tremor, headache, restlessness and anxiety/insomnia. He had a positive drug screen for benzodiazepines and cannabis, and a blood alcohol level of zero. The patient has a history of multiple detoxification treatment episodes with relapses. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms, and he denied blackouts. The patient was medically screened and admitted for inpatient level detoxification with plans for a detoxification treatment episode with Valium, vitamin replacement therapy and comfort medications, as well as the availability of nicotine replacement therapy and comfort medications. He was continued on gabapentin for anxiety and medication assisted treatment and the insomnia was treated with trazodone at 150 milligrams. The issue under review is the inpatient admission with detoxification treatment and withdrawal management. The denial was on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guideline indicating that inpatient level treatment was not medically necessary as there were no biomedical or psychiatric concerns or complicated withdrawal symptoms in the case, and that the patient was motivated for treatment. The denial indicated that residential level treatment was clinically appropriate in this case. The appeal was on the basis that the detoxification was medically necessary and that the patient was at risk for withdrawal requiring inpatient medical monitoring, as well as linkage to rehabilitation services.  

The proposed treatment is not medically necessary for this patient.
The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment, or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments in the past with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and judgment, and control of impulses. Thus, the inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and American Society of Addiction Medicine Criteria.