Appeal type: Medical necessity
Decision: Upheld

Alcohol Abuse/Addiction
Inpatient Rehabilitation

The patient presented with a request for detoxification treatment and was medically screened and admitted to inpatient level services for the detoxification of alcohol; the patient had been using up to two pints of rum plus beer daily. The patient was also using up to 3 grams of cocaine per day, up to 6 milligrams (mg) of Xanax three to six times per week, and two blunts of hallucinogens (phencyclidine) (PCP) daily. The patient's  substance use disorders had their onset in young adulthood with the initial use of alcohol and progression of the disease with subsequent use of cocaine, PCP and Xanax. The patient had no history of withdrawal seizures or delirium tremens but reported inadvertent overdoses and blackouts. The referral was prompted by the patient's desire to receive substance abuse treatment in the context of continued use of substances despite participating in multiple past treatment episodes with approximately 38 prior treatments, with the last detoxification occurring earlier in the month. The patient presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 2/67 with sweats, gastrointestinal upset, anxiety and restlessness together with normal vital signs or a mildly elevated blood pressure. Again, the patient had received past detoxification treatments.
There were no acute general medical or psychiatric issues in this case.  Laboratory assessment was unremarkable except for a urine drug screen that was positive and elevated liver functions consistent with the  history including the presence of cocaine, benzodiazepine and PCP.
A mental status examination was free of severe symptoms such as thought disorder, mood disturbance, psychosis, cognitive impairment or perceptual disturbance. The patient was deemed to be motivated to enter detoxification treatment and had minimal symptoms of withdrawal at the time of admission, as noted.
The patient was admitted and placed on a detoxification regimen with a Librium taper, comfort medications, as well as vitamin replacement therapy. The detoxification was uncomplicated about withdrawal management, though the patient required ongoing use of Clonidine for anxiety/agitation and Benadryl for insomnia. The patient received counseling and education from the staff. The clinical course was uncomplicated with continued normal vital signs and the patient was discharged with clinically appropriate aftercare and immediate referral/admission to rehabilitation substance use disorder treatment.

The health plan's determination of medical necessity is upheld, in whole.

The requested benefit of detoxification treatment and withdrawal management and other medical services could have been safely and effectively provided with lower level services. The patient in this case was using alcohol on a continuous daily basis together with other substances of abuse including PCP, cocaine and Xanax. There were no co-morbid general medical problems or co-occurring psychiatric disorders in this case that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol despite reports of blackouts and a history of overdoses. The patient was motivated for detoxification treatment and had access to substance use disorder services in the community. Moreover, the patient had recently received detoxification treatment with discharge earlier in the same month of this presentation. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, referenced below, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines, referenced below.