Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient Detoxification Admission
The insurer denied the Inpatient Detoxification Admission
The denial is upheld

The patient is an adult male. He presented for detoxification services. The patient was using alcohol on a continuous daily basis with up of 10 24-ounce beers and use of $10 worth of marijuana (cannabis) with daily use. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with a COWS (clinical opiate withdrawal scale) scales score of 6 and CIWA (clinical institute withdrawal assessment) scale score of 10 with tremor and anxiety/insomnia, as well as urges to use. He had a positive drug screen for benzodiazepines and cannabis, and a blood alcohol level of zero. The patient has a history of multiple detoxification treatment episodes. He reported two prior attempts at rehabilitation treatment with "no clean time."

The patient was admitted for inpatient detoxification. The patient's hospital course progressed without incident. The patient slept and received meals. His monitoring occurred without incident, and he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare. He left treatment against medical advice without referral for further treatment. He indicated that he could not sleep due to the noise and left angry.

The health plan denied coverage of the inpatient stay on the basis of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Guideline indicating that inpatient level treatment was not medically necessary as there were no biomedical or psychiatric concerns or complicated withdrawal in the case, and that the patient was motivated for treatment.

The appeal was on the basis of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Guidelines indicating that the detoxification was medically necessary and that guidelines did not require medical instability or psychiatric safety issues or severe psychiatric symptoms in order to be eligible for inpatient detoxification and other medical services.

No, the Inpatient Detoxification Admission was not medically necessary.
The detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment, or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments in the past with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with past treatment, as noted. Thus, the inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive treatment setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment, or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or significant biomedical issues in this case that would have required inpatient level care. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts in the denial determination. NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.