Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Inpatient. 
The insurer denied inpatient admission. 
The denial is overturned in whole.

The patient is an unemployed adult male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol, sedative-hypnotic-anxiolytic (Xanax) and stimulant (cocaine) use disorders. The patient was using up to two pints of vodka daily together with frequent use of 4 milligrams (mg) of Xanax (two bars up to 6 times per week) and with use cocaine with a quantity of 2 grams per day with intranasal administration.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a five-day Librium taper, vitamin replacement therapy, fluid replacement, and medical monitoring; the patient was tobacco dependent and offered smoking cessation treatment and nicotine replacement. Following his first day of treatment, the patient began to participate in counseling and educational sessions. Vitamins were continued, as well as comfort medications with monitoring and assistance with daily activities. He was maintained on fall and seizure precautions. His demeanor improved as he underwent detoxification treatment, and he was social with peers. Again, he participated in educational sessions and counseling during the remaining hospital stay through discharge. The patient was discharged with plans to start a rehabilitation treatment the following day with recommendations involvement in 12-step recovery meetings.

The health plan's determination is overturned in whole.

The patient in this case presented with a diagnosis of severe alcohol, sedative-hypnotic-anxiolytic, and stimulant use disorder. The presenting clinical features and history and risk for withdrawal seizures and other psychosocial complications of the substance use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario.
The adult inpatient treatment of this patient's substance use 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 substance use disorders, and the presentation with withdrawal symptoms despite use on the day of presentation. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, 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, referenced below. This answer is also consistent with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines.