Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction-Alcohol Abuse/Addiction/withdrawal. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient presented to the emergency department with complaints related to alcohol withdrawal. The patient was admitted to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder and comorbid sedative-hypnotic-anxiolytic use disorder and co-occurring substance induced anxiety and depressive disorder, unspecified bipolar disorder, and acute stress disorder. The patient was using alcohol in large quantities on a daily basis together with prescribed temazepam. At the time of presentation, she scored a 9 on the Clinical Institute Withdrawal Assessment (CIWA) scale reflecting mild withdrawal symptoms with a blood alcohol concentration of 0.265. She was tobacco dependent at 12 to 1 pack per day. She had limited treatment history with five detoxification treatment episodes without appropriate follow up. She reported psychiatric hospitalizations, ongoing treatment with psychotropic medications not consistently used due to heavy alcohol use. General medical issues included chronic obstructive pulmonary disease (COPD) with asthma, morbid obesity, neuropathy of the feet and gait problems with vascular insufficiency in her lower extremities prompting use of a wheelchair. Prescribed medications included a rescue inhaler and gabapentin, as well as duloxetine, risperidone, bupropion, and temazepam. The patient was admitted to acute inpatient level care and placed on a detoxification regimen.The patient continued to have mild to moderate withdrawal symptoms throughout the stay with CIWA scale scores from 9 to 19 peak and declining thereafter to a 12 at the time of discharge on despite receiving Valium with 5 to 10 milligrams (mg) dosages. The withdrawal symptoms included headache, tactile and visual hallucinations/sensations, agitation and anxiety, restlessness, and tremors. Treatment was continued through discharge/transfer with monitoring and assistance with daily activities with fall and seizure precautions. 

The requested health service/treatment of continued inpatient stay is considered medically necessary for this patient. 

The continued inpatient services and detoxification treatment and withdrawal management for severe alcohol and anxiolytic use disorder 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 continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with withdrawal symptoms and co-occurring psychiatric and general medical disorders. Withdrawal symptoms were managed with benzodiazepine/Valium with a CIWA protocol requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy together with fall and seizure precautions. 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 continued inpatient stay is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine  Criteria. This is consistent with New York State instruction concerning medical necessity reviews including 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 Published Guidelines.