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 an adult male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol, stimulant (cocaine), cannabis (marijuana), hallucinogen (phencyclidine [PCP]),
and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. The patient denied use of benzodiazepines despite a positive drug screen. His substance use began as a tween at age eleven with escalating use and progression of the disease with a chronic relapsing course despite at least two or more treatment episodes in the past. The patient presented with mild alcohol withdrawal. Withdrawal symptoms included tremor, insomnia, lightheadedness, and abdominal cramps with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of 8. The patient has a history of psychiatric disorder related to a stabbing incident in 1990 with diagnosis of post-traumatic stress disorder (PTSD). He had a history of substance-related treatment episodes including at least two detoxification and rehabilitation treatment episodes with relapses. The patient was admitted to acute inpatient level care and placed on a detoxification regimen. Following his first day of treatment, the patient began to participate in counseling and educational sessions. His demeanor improved as he underwent detoxification treatment, and he was social with peers and moderately motivated for participation. 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 on day #6 after completion of the detoxification protocol with plans/referral to start a rehabilitation treatment and with
recommendations for involvement in 12-step recovery meetings and medication assisted treatment with Vivitrol. The 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, withdrawal symptoms, and a lack of coping skills, as well as history of a chronic relapsing course of the illnesses. The proposed health service/treatment 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 noted in the clinical summary, 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 presentation with continued use of substances while receiving outpatient level substance-related services. The patient did require a safe and effective detoxification with withdrawal management and inpatient level monitoring 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 guidelines, and the American Society of Addiction Medicine (ASAM) Criteria, referenced below.