Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Dependence
Treatment: Inpatient Mental Health Stay
The insurer denied the Inpatient Mental Health Stay
The determination is upheld.


The patient was admitted to inpatient chemical dependency detoxification and hospitalization for a primary diagnosis of alcohol dependence with withdrawal uncomplicated. He additionally had psychiatric diagnoses of cocaine dependence, uncomplicated, and depression not otherwise specified. Records reflect that he was admitted for inpatient detoxification and was placed on a Librium protocol. 
According to a comprehensive evaluation, the patient reported daily oral use of up to one fifth a day of alcohol, along with six 16-ounce bottles over a long duration. Additionally, he endorsed smoking cocaine daily  at the amount of $60 per day. His drug screens were negative for opiates, amphetamines, hallucinogens (phencyclidine) (PCP), tetrahydrocannabinol (THC), and OxyContin and methamphetamine. He was positive for benzodiazepines, reported to have been given to him at the inpatient psychiatric hospitalization, as well as being positive for cocaine.
A psychiatric evaluation reflects that he reported a chief complaint of depression and noted psychiatric care lasts through inpatient rehabilitation services approximately two years prior in which he was prescribed Lexapro 10 milligrams (mg) every morning. He endorsed no recent psychiatric hospitalizations with the psychiatric evaluation identifying him not to be at risk of harm to self or others. The diagnostic impression was depression not otherwise specified with a recommendation to begin Lexapro 10 milligrams (mg) every morning and then for aftercare placement and would follow up with psychiatry upon completion of rehabilitation services.
A Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-AR) was completed. In this scale, he achieved an overall score of 5 out of a maximum possible of 67. He was noted to endorse the presence of anxiety at a rating of 2 between a scale of 0 to 7, paroxysmal sweats at a rating of 1 on a scale of 0 to 7, and tremors on a rating of 2 on a scale of 0 to 7.
According to the nursing progress notes, he attended five days of inpatient detoxification services for alcohol dependence and was placed on a Librium taper. All documentation based on the nursing progress notes over the days of service, as well as documentation from the clinical progress notes reflects that he engaged in no concerning behaviors, actively participated, complied with medication and progressed well. The assessment interpretive summary documented within the clinical progress notes reflect that he has a long history of alcohol use and notes that when he binges, he uses a fifth of vodka and 12 cans of beer. The patient is married, has two children and reports stable housing. He reportedly has diabetes type 2 due to his alcohol consumption and reports no mental health or legal problems.
At the time of the patient's presentation, the staff completed a detox Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) to assist with a level of care determination. He was identified to be incapacitated, evidencing no risk of physical harm, no risk of severe withdrawal, no risk due to complications or abnormalities, but presenting with risk of moderate withdrawal and a lack of support for early abstinence. As a result, they determined inpatient medically supervised withdrawal was appropriate. At issue is the medical necessity of an inpatient mental health stay.

The patient was medically stable, did not have a history of seizures or delirium tremors and did not have a history of complicated withdrawal. He was not suicidal, homicidal or psychotic. He was motivated to be in treatment, had access to sober support and determined that treatment at a substance use residential rehabilitation level of care would appear more appropriate. He was not experiencing symptoms of functional impairment that created an imminent risk of harm to self or others. These findings are supported by the medical records provided and available. Documentation reflects that the patient had completed two days of some form of inpatient care identified at one point as being for psychiatric care and another point at being for detoxification services in the two days prior to admission for inpatient detoxification for the dates in question.
Furthermore, drug screening reflected the patient had not presence of alcohol in his system. Additionally, the completion of the CIWA identified the claimant achieved a score of 5 out of a possible total of 67, suggesting that the patient was experiencing minimal symptoms associated with withdrawal. The completion of the detoxification Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) that the hospital staff used to support medically supervised inpatient detoxification was erroneously indicated and based on the findings provided within the medical records would have been more appropriate to support medical detoxification at an outpatient level of care.
The patient did not present based on findings available within the medical records with symptoms that warranted the need for inpatient care. The patient did not present through examination findings at acute risk and evidenced minimal symptoms of withdrawal associated with his substance use. Furthermore, he was not noted to be an imminent risk of harm to self or others based on his psychiatric evaluation. Given the totality of the findings provided, the requested service/treatment of inpatient mental health stay was not medically necessary. The medical records provided for review in this case do not support the patient as functionally impaired or requiring medically necessary for the patient to receive inpatient detoxification or inpatient psychiatric care.