Appeal type: Medical necessity
Decision: Upheld

The patient is a male, self-referred and requesting detoxification from alcohol. The patient was using alcohol on a daily basis with up to three six-packs together with cannabis. He had a longstanding history of alcohol use and had been exposed to substance use disorder treatment in the past. He reported that he had been sober for 17 years while in a positive relationship but had relapsed with combined use of alcohol and cannabis class substances of abuse.
The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms; the patient was medically screened and his Clinical Institute Withdrawal Assessment (CIWA) scale score was 9 reflecting mild withdrawal symptoms or signs with sweats, mild tremor and report of joint pain, irritability and anxiety, as well as cravings. There was no reported use of other illicit drugs or other drugs of abuse. There were no general medical issues in this case and vital signs were normal. Again, the patient was medically screened and cleared for admission to detoxification treatment.
There was no psychiatric comorbidity diagnosed in this case. Mental status examination revealed mild symptoms of anxiety and irritability in association with mild withdrawal symptoms and reports of insomnia with no severe psychiatric symptoms and limited insight and motivation for treatment.
The patient is unemployed and had limited social supports. He was receiving SSI (social security income). He did not report legal issues or trauma history.
The patient was admitted for inpatient detoxification and other medical services following the assessment for safety issues and medical clearance. He was prescribed tapering dosages of Librium per the detoxification protocol and he received vitamin replacement therapy and other supportive measures including the availability of as needed (prn) medications for insomnia and anxiety. The patient's hospital course progressed without incident. His monitoring occurred without incident throughout the inpatient stay. The treatment program offered counseling and educational services with recommendation for clinically appropriate aftercare. He was discharged against medical advice without completion of the detoxification treatment. The patient declined recommendations for clinically appropriate aftercare and rehabilitation substance-related treatment; no aftercare was accepted.

The health plan's determination is upheld.

The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care in keeping with NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorder with cannabis, did not require or warrant the structure of an inpatient setting or 24-hour monitoring, as noted in the answer to question 1. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cannabis class substances. Moreover, the patient had been evaluated and cleared with regard to safety concerns and general medical issues, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment for the substance use disorders.
Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for the alcohol and cannabis use disorders in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.