Appeal type: Medical necessity
Decision: Overturned

The patient is a male who presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid, cocaine, and cannabis class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to two pints of liquor and 12 beers. He had multiple prior substance use disorder treatments including an interval of sobriety for two years while in a healthy relationship with family and while participating in treatment. However, he reported up to 100 previous detoxification treatments and 5 previous rehabilitation substance use disorder treatment episodes with more recent treatments.

The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and prn medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished over the first four days of admission. He was socially withdrawn but participating in counseling and educational sessions. From the next day forward, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.

Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge. Again, the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.

The health plan denied the last day of the admission as not medically necessary. The health plan's determination is overturned. 

The requested benefit of continued inpatient detoxification treatment and withdrawal management and monitoring and other medical services for the last day of service could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with multiple other substances of abuse that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. The continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services. And it was in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of American Society of Addiction Medicine (ASAM) Criteria and 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, referenced below.