Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Admission
The insurer denied the Inpatient Detoxification Admission
The denial is upheld

The patient is a male with diagnoses of alcohol dependence with intoxication; cocaine dependence  uncomplicated; sedative, hypnotic, or anxiolytic dependence - in remission; nicotine dependence with cigarettes  uncomplicated; schizoaffective disorder; and insomnia. The question is whether inpatient detoxification treatment is medically necessary.

A comprehensive evaluation note describes the patient as alert, oriented, and cooperative with cognition intact, and that he denied SI (suicidal ideation), HI (homicidal ideation), or any safety concerns at the time of admission. His physical exam was noted to be within normal limits. A CIWA (clinical institute withdrawal assessment) score is recorded as 6. Detox LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) note states that the patient can be admitted to inpatient/residential medically supervised withdrawal service due to the expectation of moderate level of withdrawal symptoms based on the amount of alcohol and/or other substances used by the patient, history of past withdrawal syndromes and/or medical condition of the patient; however, it also states that he patient does not need medically managed level of withdrawal and stabilization.

During his inpatient rehab admission, the patient's treatment included a medication regimen consisting of a Librium taper and comfort medications. A recovery care plan lists a goal of establishing and maintaining abstinence and attending rehab with objectives of developing coping skills to prevent relapse. He continued to deny any safety concerns, SI/HI (suicidal ideation/homicidal ideation), or withdrawal symptoms throughout admission. Nursing notes indicate that the patient was alert and oriented throughout admission. Nursing notes note that the patient denied any withdrawal symptoms. He completed his Librium taper.

A clinical progress note notes that a staff member had a brief intervention with the patient to discuss his history of leaving against medical advice after being transitioned from inpatient detox to rehab status, which was the likely plan. The patient was adamant that he was committed to completing the rehab portion of his treatment.

Clinical progress note states that patient had completed the 5-day protocol and had been medically cleared for regular discharge. He had accepted a referral to the third floor for aftercare.

The patient requested discharge against medical advice from the inpatient facility, noting that he had a personality conflict with the clinical director. At issue is inpatient detoxification level of care.

A medical director used Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for Substance Abuse Inpatient Rehabilitation criteria for the final coverage determination and concluded that medical necessity for an inpatient detox level of care was not met because the patient was not acutely ill from alcohol-related and/or substance-related addiction or dependence; the patient did not require medical management as he did not have severe withdrawal or risk of severe withdrawal symptoms; he had low CIWA (clinical institute withdrawal assessment) scores; the patient was alert and fully oriented without significant distress over the course of his hospitalization; he was not ataxic, hyperreflexic, desirous, hallucinatory, or showing persistent elevation of blood pressure or heart rate; the patient did not show severe sedative-related withdrawal with similar symptoms; and, in terms of his psychiatric status, he was not suicidal, homicidal, psychotic, or hallucinatory. As such, the reviewer noted that the patient's needs could have been met at an alternate level of care, such as the residential rehabilitation level of care.

No, the Inpatient Detoxification Admission was not medically necessary.

The patient's American Society of Addiction Medicine (ASAM) Patient Placement Criteria Rating was as follows:
(Dimension 1) Risk: 1
Adequate ability to tolerate or cope with withdrawal discomfort
Mild to moderate intoxication, or signs, symptoms interfere with daily functioning, but not a danger to self or others
Minimal risk of severe withdrawal resolving, CIWA (clinical institute withdrawal assessment) score 3-7
(Dimension 2) Risk: 0
Fully functioning with good ability to cope with or tolerate physical discomfort
No biomedical signs or symptoms are present
(Dimension 3) Risk: 0
No current/chronic psychiatric, psychological, behavioral, emotional, or cognitive problems that create risk or complicate treatment
(Dimension 4) Risk: 3
Exhibits inconsistent follow through and shows minimal awareness of alcohol and other drug abuse
Appears unaware of need for change and unwilling to follow through with treatment recommendations
(Dimension 5) Risk: 4
Repeated treatment episodes have had little positive effect on functioning
Daily intoxication
Moderate use of drugs
(Dimension 6) Risk: 1
Has passive support in environment

Based on patient's risk ratings, a lower level of care, such as residential rehabilitation, would have been appropriate for treating the patient's substance.

Additionally, the patient does not meet criteria for inpatient level of care using LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria. The patient was not experiencing a life-threatening medical condition or severe psychiatric crisis, was not experiencing significant functional impairment due to his substance abuse, and was not experiencing acute withdrawal symptoms from alcohol or benzodiazepines. He did not have a history of life-threatening withdrawal syndromes or withdrawal seizures. He was not experiencing a severe medical problem or serious psychiatric symptoms that needed to be managed in an inpatient rehab setting in order for treatment for his substance abuse to be effective. He did not endorse using substances in hazardous situations or in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. He did not have any personal or interpersonal skills deficits. He was not documented to have been exhibiting predatory behavior that would have likely caused harm to others in a congregate setting. He did not report strong cravings or urges to use that were unmanageable or behavioral or emotional instability that would require stabilization with medical oversight in a residential setting. Based on LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) guidelines, the patient could have been appropriately managed at the residential rehabilitation level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

As noted above, the severity of patient's symptoms based on ASAM (American Society of Addiction Medicine) patient placement criteria and LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) patient placement guidelines show that the patient's condition could have been managed at a lower level of care than inpatient detoxification. There is no documentation of moderate or severe acute withdrawal symptoms, he did not have an acute medical condition that required inpatient treatment, and he did not endorse SI (suicidal ideation), HI (homicidal ideation), or any other severe psychiatric symptom that would require inpatient treatment. He also denied any history of any serious psychiatric diagnoses. His symptoms could have been managed at a lower level of care.