Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Alcohol Abuse
Treatment: Inpatient Admission for Chemical Dependency Detoxification
The health plan denied the request for Inpatient Admission for Chemical Dependency Detoxification. 
The health plan's determination is overturned.

The patient is an adult male who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of moderately severe alcohol and stimulant (crack-cocaine) and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. 
The patient has co-occurring psychiatric disorders that included unspecified anxiety and depressive disorder treated with Lexapro. He denied recent psychiatric hospitalization, or suicidal or self-harming behaviors.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with Librium together with vitamin replacement therapy, and medical monitoring.  His mental status examination included persistent symptoms of depression with associated symptoms of anxiety, fatigue and insomnia. He had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He was treated with Lexapro and as needed (prn) Vistaril. Vitamins were continued, as well as the availability of comfort medications with monitoring and assistance with daily activities.
 The patient was discharged with recommendations for clinically appropriate aftercare, as well as recommendations for involvement in 12-step recovery meetings with Alcoholic Anonymous (AA). He was discharged  with referral for rehabilitation substance use disorder treatment and follow up with his primary care physician and provider of mental health care.

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

Yes, the requested health service/treatment of the Inpatient Admission for Chemical Dependency and Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services,  is medically necessary for this patient.
   
The proposed inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at an alternative level of care. The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and impairment of functioning. The patient's general medical conditions and co-occurring psychiatric disorders were treated with continued use of his medications and monitoring. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments and other medically necessary treatment. In this case scenario, it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at an alternative level of care.