Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Admission
The insurer denied: Inpatient Detoxification Admission
The denial is overturned.

The patient is a homeless and unemployed adult male. He was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol, stimulant (cocaine), and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. The patient was using up to two pints of liquor together with a six-pack of beer daily together with up to $300 worth of cocaine. He denied use of benzodiazepines despite a positive drug screen. His substance use began at age 15 with escalating use and progression of the disease with a chronic relapsing course despite at least two or more treatment episodes in the past. He reported that the longest period of sobriety was about two years. The patient presented with moderate alcohol withdrawal at the time of admission. Withdrawal symptoms included tremor, sweats, nausea, insomnia, lightheadedness, and agitation with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 15. He had a history of substance-related treatment episodes including at least two detoxification and rehabilitation treatment episodes with relapses. There were no acute medical issues or general medical concerns though he had a history of syphilis. The patient was admitted to acute inpatient level care and placed on a detoxification regimen. He participated in educational sessions and counseling while in treatment with motivational interviewing with the goal of proceeding to rehabilitation treatment and considering medication assisted treatment. The patient was discharged after completion of the detoxification protocol with plans/referral to start a rehabilitation treatment and with recommendations for involvement in 12-step recovery meetings. Denial determination was based on Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines indicating that treatment could be safely provided with lower-level care, and that the patient was motivated with no severe withdrawal symptoms or history of complicated alcohol withdrawal. The appeal was based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and the presenting clinical features including use of multiple substances of abuse, moderately severe withdrawal symptoms with a Clinical Institute 
Withdrawal Assessment of 15, and a lack of coping skills, as well as history of a chronic relapsing course of the illnesses.

The requested health service was medically necessary for this patient.

The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol and other substance use disorders, and other services could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder and the clinical features of the case. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring. Thus, the patient did require a safe and effective detoxification with withdrawal management and inpatient level monitoring as 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 a lower level of care. Medical necessity for the admission and the continued inpatient services is met in this case and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria. This answer is also consistent with New York State instruction concerning medical necessity reviews including the required application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines. Therefore, the requested health service is medically necessary for this patient.