Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea, vomiting, and abdominal pain in the context of severe alcohol use disorder.
Treatment: Inpatient Detoxification Treatment.
The insurer denied the Inpatient Detoxification Treatment.
The denial is overturned.

The patient is a male who presented to an emergency department with nausea, vomiting, and abdominal pain in the context of severe alcohol use disorder. The patient has a history of severe substance use disorder with daily use of alcohol and intermittent use of cannabis (marijuana). He has a history of prior detoxification and rehabilitation treatment episodes with relapses and no recent sober time. 

At the time of presentation to the emergency department, the patient reported functional decline as the substance use/disease had progressed. The patient provided no past history of withdrawal seizures or delirium tremens, but did report severe alcohol withdrawal symptoms in the past. He was admitted for inpatient level care with plans for withdrawal management and detoxification and stabilization with an Ativan protocol with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) monitoring and supportive measures. 

The medical screening had revealed evidence for acute pancreatitis, elevated liver functions and a drug screen that was positive for tetrahydrocannabinol (THC), consistent with history. His examination revealed abdominal tenderness with complaints of epigastric pain, as well as withdrawal symptoms including nausea, vomiting, tremors and chills with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score in the mild range. 

The patient was admitted for inpatient treatment with detoxification protocol, supportive measures, and withdrawal management. He received tapering dosages of Ativan and replacement of vitamins and fluids with the availability of nicotine replacement for tobacco dependence, as well as comfort medications and as needed (PRN), medications prescribed for pain, anxiety, and insomnia. He was prescribed pantoprazole, and gabapentin to serve as an anti-craving medication or medication assisted treatment.

The patient's hospital course progressed without incident. Vital signs remained normal with occasional bradycardia and sinus rhythm on electrocardiogram-- that was present on his initial presentation. The patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout his brief hospital course. He quickly stabilized and arrangements were being made for a referral to rehabilitation substance use disorder treatment and follow up. He was discharged with recommendations for continued medications as noted, and involvement with self-help groups for support of a recovery, as well as recommendations for clinically appropriate aftercare.
The health plan denied coverage for the requested services on the basis of New State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that the patient could have been sufficiently managed with lower-level care and stabilization in a residential setting. The denial determination indicated that the withdrawal symptoms were mild, that the patient had no general medical or psychiatric symptoms requiring inpatient level care, and, that the patient was stable with employment and housing.

In appeal, the treatment facility indicated that the requested services were medically necessary in keeping with 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 guidelines. The appeal argued that the admission to hospital inpatient care was medically necessary and that the patient required detoxification and stabilization in keeping with Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) guidelines and in view of the severity of the alcohol use disorder that included general medical complications.

Yes, the proposed treatment, inpatient hospital level care for detoxification treatment and withdrawal management and stabilization with monitoring and other medical services was medically necessary for this patient in keeping 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 prevailing standards of medical practice.
The requested benefit of inpatient admission for detoxification treatment and withdrawal management and monitoring and other medical services 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 with daily use, and one other drug of abuse (marijuana) with a presentation and history that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.

Inpatient hospital level care with detoxification, as necessary, and other treatments could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided in the emergency department and continued at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms and maintaining abstinence which were being effectively addressed with inpatient level monitoring with an Ativan protocol and supportive measures. The patient had associated clinical features that included lack of sober supports and functional impairments with unemployment and general medical complications of the alcohol use disorder-contrary to the denial determination. 

Thus, the appeal did appropriately indicate the necessity for the adult inpatient stay and detoxification treatment of this patient's substance use disorders that did warrant the hospital admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management and stabilization, as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Moreover, the stage of change was contemplative at best and the patient's lack of awareness or insight regarding the severe alcohol use disorder and risk for medical complications. 

Medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of New York Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria-referenced below. The health plan's denial on the basis of New York Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria is not reasonable and attempting detoxification and other treatment in the emergency department or with lower-level treatment is not in the best interest of the patient or safe in this case scenario.

No, the health plan, in its determination of medical necessity, did not act reasonably with sound medical judgment and in the best interest of the patient.
The health plan's denial on the basis of New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria is not reasonable, and attempting appropriate treatment with lower-level services, as the health plan recommended, is not in the best interest of the patient, or safe in this case scenario. The requested benefit of Inpatient Hospital detoxification treatment and withdrawal management and monitoring and other medical services is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. 

The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower-level services. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of the American Society of Addiction Medicine (ASAM) Criteria, Level of Care Utilization System (LOCUS) Guidelines, and application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.