Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Use Disorder, Opioid Use Disorder.
Treatment: Inpatient Chemical Dependency Detoxification.

The health plan denied the requested inpatient hospitalization. The health plan's determination is upheld.

The patient is a male who received inpatient level of care for his substance use disorders. Diagnoses were listed as cocaine dependence, alcohol dependence with withdrawal, opioid dependence with intoxication, anxiety, bipolar, depression. The patient reported a history of substance use disorder difficulties and past treatment on five occasions. He reported some extended periods of sobriety.  A precipitant to the recent relapse was stated to be his father's recent death. The patient reported that he did not have stable housing on admission. On admission, the patient reported drinking 2 pints of liquor and 140-ounce beer per day. He also used six bags of heroin intranasally and $50 of crack cocaine daily. He was additionally taking Methadone pills that were not prescribed to him one to three times over the prior 30 days. His blood alcohol level was zero on admission and urine drug screen was positive for opiates, cocaine, and Methadone. Initial alcohol withdrawal score was 8 and opioid withdrawal score was 12.
An appeal letter states that he did not have any prior clean time, though medical records indicate that he reported episodes of clean time in the past of up to seven years. The patient reported multiple prior treatment episodes at various levels of care including residential and outpatient. Clinical records indicate that the patient was adherent to prescribe treatments and took advantage of various treatment modalities offered.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis. The substance with the greatest potential for harm to self or others was alcohol. The patient clearly met criteria for diagnosis with multiple substance use disorders including alcohol, cocaine, and opiates. The patient did not meet criteria for full sustained remission from a substance use disorder. There was no evidence of serious medical symptoms that needed to be managed in an inpatient rehabilitation setting. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting to be effective. The clinical documentation does not establish that the patient was using in ways that would lead to imminent danger. The patient did have interpersonal deficits with difficulties maintaining employment and unstable relationships. The patient did not exhibit predatory behavior. The patient did require oversight related to strong cravings that made abstinence unmanageable.
This patient had serious and long-term substance use disorders though he also had some periods of sobriety in the past. The patient did not exhibit unstable medical or psychiatric problems. The patient had mild to moderate withdrawal symptoms that could have been managed at a lower level of care. Based on your responses, the LOCADTR level of care is stabilization services in a residential setting.