Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted following medical screening in the emergency department, to acute inpatient level services for monitoring and detoxification and withdrawal management of moderately severe alcohol and stimulant (crack-cocaine) and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. The patient was using an anxiolytic (Xanax) on an intermittent and frequent basis. The patient was using large amounts of alcohol with up to one pint of liquor per day plus beer, and crack cocaine. The patient had experienced severe alcohol/anxiolytic withdrawal in the past and had moderately severe withdrawal at the time of admission with sweats, tremors, nausea, headache, and auditory hallucinations, as well as anxiety, irritability and restlessness. She had experienced severe withdrawal symptoms in the past requiring detoxification including detoxification treatment in the past year with relapse. She also reported frequent blackouts, but no history of alcohol or drug withdrawal seizures or delirium tremens.
The patient has a co-occurring psychiatric disorder that included unspecified depressive disorder treated with Wellbutrin and trazodone. She denied psychiatric hospitalization, or suicidal or self-harming behaviors.
General medical issues included hypertension, gastroesophageal reflux disease (GERD), asthma, osteoporosis and genital herpes treated with amlodipine, pravastatin, famotidine, Zovirax and Singulair with albuterol inhaler. 
The patient was admitted to acute inpatient level of care and placed on a detoxification regimen with a Librium together with vitamin replacement therapy and medical monitoring. Following her third day of treatment, the patient began to participate actively in counseling and educational sessions, as her withdrawal symptoms diminished and she was feeling better. Her mental status examination included persistent symptoms of depression with associated symptoms of anxiety, fatigue and insomnia. She had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. She was treated with Wellbutrin and trazodone, as noted and as needed (PRN) medications to address pain, anxiety, agitation insomnia. Vitamins were continued, as well as the comfort medications and monitoring, and assistance with daily activities.
The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. She did continue with detoxification treatment was maintained on fall and seizure precautions. The health plan's determination is overturned. The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and impairment of functioning. Withdraw symptoms were managed with tapering dosages of benzodiazepine requiring monitoring and as needed medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. General medical and co-occurring psychiatric disorders were treatment with continued use of the patient's medications. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse 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 NY State Office of Alcoholism and Substance Abuse Services (OASAS) LOCADTR 3.0 Criteria and Guidelines.