Appeal type: Medical necessity
Decision: Overturned

The patient is a male who was admitted to acute inpatient level services for detoxification and withdrawal management of severe alcohol and moderately severe cannabis use disorder. He was using up to one liter of liquor daily and up to one gram of marijuana daily. The patient has a past history of detoxification/substance use disorder treatment  with relapse. He had no history of withdrawal seizures or delirium tremens. The patient presented with general medical issues that included withdrawal symptoms and history of human immunodeficiency virus (HIV) and purified protein derivative (PPD) positivity in the context of tobacco dependence. Additionally, the patient has a history of bipolar mood disorder previously treated with Wellbutrin. He has a history of suicidal behavior and psychiatric hospitalization. The patient's self-referral was prompted by health concerns and the desire to take better care of himself, and severe psychosocial stressors that included homelessness and unemployment and a lack of social supports.

The patient remained functional throughout the hospital course and was better able to perform basic activities of daily living with resolution of his withdrawal symptoms with a Clinical Institute Withdrawal Assessment (CIWA) scale score that had decreased from 17 to 2. He participated in counseling sessions, educational sessions and group meetings with peers. Thus, he was provided education and counseling with regard to subsequent care and met with the case manager to address stressors that included housing, primary support, financial, occupational and social environment domains, as he was unemployed and homeless. With regard to the patient's living situation and social environment, the patient was concerned with the drug infested neighborhood and social environment with planning for sober housing. The patient completed the detoxification treatment and was discharged with recommendations for clinically appropriate aftercare to include immediate transfer for substance use disorder rehabilitation treatment and mental health services with continuation of Wellbutrin, and primary care for his general medical issues, and recommendation for involvement in 12-step recovery groups with the obtainment of a sponsor.

The health plan's determination is overturned.

Yes, the requested health service/treatment inpatient services for detoxification, withdrawal management and stabilization are medically necessary for this patient. The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol and cannabis use disorders, and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders and associated general medical complications and severe psychosocial stressors did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorder, and the continued presence of symptoms related to co-occurring psychiatric disorder requiring treatment. Withdrawal symptoms were managed with tapering dosages of benzodiazepine requiring monitoring and as needed (prn) medications, as well as comfort medications. The patient's history of alcohol and cannabis use (frequency and quantity) together with a co-occurring mood disorder does reflect the seriousness of this case such that an inpatient setting was necessary thru discharge. The patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from alcohol or cocaine if detoxification and treatment were to be attempted at a lower level of care.

Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer is also consistent with the application of New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below that requires that this patient receive services at the inpatient level of care for the duration of treatment provided in this case.