Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male who was noted to have been admitted to a medically monitored intensive inpatient detoxification level of care. He was noted to have been diagnosed with alcohol use disorder. He was also noted to have been diagnosed with generalized anxiety disorder. The patient was reported to have been admitted for detoxification from alcohol and treatment of depression in the context of significant psychosocial stressors. He was reported to have expressed suicidal ideations at the time of his presentation to the emergency room. The patient was noted to have received treatment in the emergency room including intravenous fluids prior to being admitted to the acute inpatient detoxification level of care. His girlfriend was reported to have recently broken up with him.

The patient was not reported to have any significant unstable vital signs or abnormal biochemical parameters at the time of his admission to the inpatient detoxification level of care. He was not reported to have any significant withdrawal symptoms at the time of his admission as indicated by elevated scores on withdrawal rating scales including the Clinical Institute Withdrawal Assessment Alcohol (CIWA). There was no indication that the patient had any significant physiological withdrawal symptoms that required 24 hour medical and nursing care.

The patient was not reported to have any suicidal or homicidal ideations with plans or intent. He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient had no significant ongoing medical problems that required hospital-based interventions. He was not reported to have any functional impairments including activities of daily living and self-care. He was not reported to have had any significant adverse effects from medications. He was noted to have been discharged from the inpatient detoxification level of care.

No, the proposed treatment (acute inpatient detoxification level of care) was not found to be medically necessary.

Based on the American Society of Addiction Medicine (ASAM) criteria and current peer reviewed, evidence-based medical literature, the requested acute inpatient detoxification level of care was not found to be medically necessary. The clinical information provided does not indicate that the acute inpatient detoxification level of care was the least restrictive setting that was medically necessary or that it would be successful in treating the patient's symptoms.

The patient is a male who was noted to have been admitted to a medically monitored intensive inpatient detoxification level of care. He was noted to have been diagnosed with alcohol use disorder. He was also noted to have been diagnosed with generalized anxiety disorder. The patient was reported to have been admitted for detoxification from alcohol and treatment of depression in the context of significant psychosocial stressors. The patient was noted to have been provided with individual, group and milieu therapy in addition to medication management. He was noted to have been placed on alcohol withdrawal protocol.

The patient was not reported to have any significant unstable vital signs or abnormal biochemical parameters at the time of his admission to the inpatient detoxification level of care. He was not reported have any significant withdrawal symptoms at the time of his admission as indicated by elevated scores on withdrawal rating scales including the Clinical Institute Withdrawal Assessment Alcohol (CIWA). There was no indication that the patient had any significant physiological withdrawal symptoms that required 24 hour medical and nursing care.

The patient was not reported to have any suicidal or homicidal ideations with plans or intent. He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient had no significant ongoing medical problems that required hospital-based interventions. He was not reported to have any functional impairments including activities of daily living and self-care that represented a change from his baseline. He was not reported to have had any significant adverse effects from any prescribed medications. 

Based on the American Society of Addiction Medicine (ASAM) criteria and the clinical information provided, the patient did not meet criteria for medically monitored high intensity inpatient detoxification level of care.

Dimension 1 (Acute intoxication or withdrawal potential): There was no indication that the patient had any acute intoxication or severe withdrawal potential. There was no indication of the patient had any significant physiological withdrawal symptoms or had difficulty tolerating or coping with any withdrawal symptoms. The patient was not noted to have any significant risk for severe withdrawal. Risk Rating - 1
Dimension 2 (Biomedical conditions and complications): The patient was not noted to have any significant comorbid medical conditions that required inpatient treatment. There was no indication of the patient had any significant medical complications related to substance abuse. The patient was not reported have any significant physical discomfort. Risk Rating - 0
Dimension 3 (Emotional, behavioral or cognitive conditions and complications): There was no indication that the patient had any significant ongoing symptoms of any comorbid psychiatric conditions. The patient was not reported to have any active suicidal or homicidal ideations. There was no indication that the patient had any symptoms of psychosis or mania. The patient was noted to have a history of depression and anxiety. However, symptoms were noted to have been largely stable with ongoing interventions.) Risk Rating - 1
Dimension 4 (Readiness to change): The patient was noted to have been engaged and participating in treatment. He was noted to be motivated to remain sober. However, he was noted to have some ambivalence regarding treatment. Risk Rating - 1
Dimension 5 (Relapse, continued use or continued problem potential): The patient was reported to have a history of relapses in the past. He was noted to have some vulnerability related to a history of behavioral health symptoms. However, he was noted to have fair self-management and relapse prevention skills. Risk Rating - 1
Dimension 6 (Recovery/living environment): The patient was noted to have a supportive family and social supports. He was noted to have recent issues with relationships including breakup from his girlfriend. Risk Rating - 1

Therefore, the proposed treatment (acute inpatient detoxification level of care) was not found to be medically necessary. The patient may have been treated safely and effectively in a less restrictive setting.

Yes, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.

The patient is a male who was noted to have been admitted to a medically monitored intensive inpatient detoxification level of care between. He was noted to have been diagnosed with alcohol use disorder. He was also noted to have been diagnosed with generalized anxiety disorder. The patient was reported to have been admitted for detoxification from alcohol and treatment of depression in the context of significant psychosocial stressors. However, there was no indication that the patient had any significant withdrawal symptoms that required inpatient level of care at the time of his admission. There was no indication that the patient had any unstable vital signs or abnormal biochemical parameters. The patient was not reported to have any significant comorbid medical or behavioral health conditions that required 24 hour medical and nursing care. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.