Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult male.  He presented with a request for detoxification services.  The patient reported that he was using alcohol and opioid (heroin) class substances of abuse with a past history of poly-substance use.  He reported using up to 48 ounces of beer three to six times per week and approximately two bundles of heroin daily.  He presented without a score on the CIWA (clinical institute withdrawal assessment) scale and COWS (clinical opiate withdrawal scale) score of 1 with complaints of anxiety and insomnia, as well as sweats and gastrointestinal upset.  He has a history of unspecified anxiety and bipolar mood disorders with no current treatment, but a history of psychiatric treatment and hospitalization.  He had received multiple past substance use disorder treatments, including recent detoxification treatment a few days prior.  He later admitted to using Fentanyl the day of his admission despite a negative drug screen that was only positive for methadone consistent with his recent detoxification treatment episode.

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, but he was diagnosed with hypertension, obesity and asthma with a rescue inhaler.

The patient was medically screened and admitted for inpatient level detoxification with plans for a five day detoxification treatment episode with Methadone, vitamin replacement therapy and comfort medications.  His laboratory assessment was normal or unremarkable, as well as his physical examination that was consistent with history. Vital signs were normal on presentation and throughout his stay.

On 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, severe mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. 

The patient presented with anxiety and insomnia.  He had fair control of his impulses. 

The patient was admitted for inpatient detoxification with a five day Methadone taper.  Vital signs were consistently normal and the patient was in no apparent distress.  The patient slept and received meals the first hospital day.  His monitoring occurred without incident, and he was to attend group sessions and receive counseling with recommendation for clinically appropriate aftercare.  He also had the opportunity to participate in 12-step meetings.  He received vitamin replacement therapy.  He reported "not feeling well" and was discharged with transfer to another hospital for continuing care.

The proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care.  The treatment 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 unspecified anxiety and bipolar disorder and ongoing substance use disorders with alcohol and opioid class substances of abuse.  The patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that warranted an inpatient level admission and treatment.  There were no severe symptoms of withdrawal or biomedical issues, and the patient had received detoxification treatment and rehabilitation substance use treatment recently.  The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes.  Thus, an inpatient admission was not medically necessary.