Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild Alcohol Withdrawal Symptoms
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female. She presented to an emergency department with nausea, vomiting, diarrhea 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). She has a history of multiple detoxification and rehabilitation treatment episodes with relapses and no sober time. She also had a history of alcohol-related pancreatitis, and peripheral neuropathy related to longstanding use of alcohol.

At the time of presentation to the emergency department, the patient reported functional decline as the substance abuse/disease had progressed. The patient provided no past history of withdrawal seizures or delirium tremens, but did report severe alcohol withdrawal symptoms and frequent blackouts. She was admitted for inpatient level care with plans for withdrawal management and detoxification and stabilization with Librium and supportive measures. The medical screening had revealed evidence for bacteria and blood in the urine, elevated liver functions and a drug screen that was positive for THC (tetrahydrocannabinol) and consistent with history. Her examination revealed abdominal tenderness with complaints of epigastric pain.

The patient has a history of psychiatric disorder, anxiety, and past treatment with Zoloft, but no history of suicidal or self-harming behaviors.

On Mental Status Examination, there were no severe symptoms, and no safety concerns with regard to risk of harm to self or others. The patient displayed limited insight, and intact judgment. She demonstrated symptoms of anxiety with generalized symptoms including insomnia, and anxious affect together with symptoms related to the alcohol use associated with a blood alcohol level of 388 on admission. She was cooperative with normal speech and linear thought processing. There were no severe symptoms of cognition, or psychosis, perceptual disturbance or mood cycling.

The patient was admitted for inpatient treatment with detoxification protocol, supportive measures, and withdrawal management. She received tapering dosages of Librium and replacement of vitamins and fluids and magnesium with the availability of counseling and comfort medications and prn (as needed) medications prescribed for pain, anxiety, and insomnia. She was started on Celexa to address anxiety and gabapentin for neuropathy and 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 tachycardia that was present on her initial presentation. The patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout her brief hospital course. She quickly stabilized and arrangements were being made for a referral to rehabilitation substance use disorder treatment and outpatient mental health services or follow up. She 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 MCG (Milliman Care Guidelines) Criteria indicating that the patient could have been sufficiently managed in the emergency department and discharged with lower-level care.

The treatment facility indicated that the requested services were medically necessary in keeping with MCG (Milliman Care Guidelines) level of care guidelines for alcohol and psychoactive substance withdrawal and common complications and conditions (MCG [Milliman Care Guidelines]-035). The appeal argued that the admission to hospital inpatient care was medically necessary and that the patient required IV (intravenous) replacement with fluids and magnesium, psychiatric consultation, and stabilization in keeping with MCG (Milliman Care Guidelines) guidelines.

Yes, the Inpatient admission was medically necessary.
The inpatient admission was medically necessary for this patient in keeping 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 and prevailing standards of medical practice.

The requested benefit of Inpatient Hospital 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 intermittent use 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 a Librium protocol and supportive measures. The patient had associated clinical features that included lack of sober supports and functional impairments.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders 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 have been attempted at a lower level of care.

In summary, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of NY OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria-referenced below. The health plan's denial on the basis of New York LOCADTR (level of care for alcohol and drug treatment referral) 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 MCG (Milliman Care Guidelines) 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.

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 should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of ASAM (American Society of Addiction Medicine) Criteria, LOCUS (Level of Care Utilization System) Guidelines, and application of NY State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria, referenced below.