Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse Disorder.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male, who presented to the emergency department with a request for detoxification services.  The patient was using alcohol on a continuous daily basis with up of two pints of liquor and use of $40-200 worth of crack cocaine with daily use, as well as $10 worth of cannabis with daily use of marijuana.  He presented with mild symptoms of withdrawal in the context of the alcohol use disorder.  He had a positive drug screen for cocaine and cannabis consistent with history.  The patient has a history of detoxification treatments including a recent discharge.

The patient had no history of a co-occurring psychiatric disorder or treatment and denied past history of suicidal or self-harming behavior.

The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.  The patient had no acute general medical problems.  He was tobacco dependent.  He was medically screened and admitted for inpatient level detoxification with plans for a five-day detoxification treatment episode with Librium, vitamin replacement therapy and comfort medications, as well as the availability of nicotine replacement therapy and comfort medications.

Mental Status Examination: The patient was cooperative with good eye contact.  Speech was clear and thought production was linear and logical.  There were no severe symptoms on mental status examination, such as thought disorder, cognitive impairment, mood disturbance, psychosis or perceptual disturbance, or suicidal ideation.  He presented with anxiety/irritability and motor agitation that was mild.  He had fair control of his impulses.  He reported anxiety and restlessness reflecting withdrawal symptoms from alcohol.

The patient is single, homeless and unemployed.  He had limited social supports from family and peers were using substances of abuse.

The patient was admitted for inpatient detoxification.  The patient's hospital course progressed without incident.  The patient slept and received meals.  His monitoring occurred without incident, and he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare.  His Clinical Institute Withdrawal Assessment (CIWA) scale decreased from 12 to 9.  The following day, the patient requested discharge and left treatment against medical advice.  He was advised on further treatment as clinically appropriate. 

No, the proposed treatment, Inpatient Admission was 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 cocaine 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 recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary.  The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past treatment, as noted.  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 OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. 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 symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. And, NY State Office of Addiction Services and Supports Level of Care Determination (OASAS LOCADTR) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.