Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Substance abuse Inpatient.
The health plan's determination is overturned in whole. The inpatient substance abuse stay was medically necessary.

The patient is homeless and unemployed who was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol and stimulant (cocaine and crack cocaine) use disorders. The patient was using up to two pints of liquor plus 40 ounces of beer daily with use of crack cocaine, as well as intermittent use of cocaine at a cost of $1000 when using. Patient had a longstanding history of cocaine and alcohol use beginning in adolescence with a twenty year period of sobriety and relapse associated with psychosocial stressors including primary support, housing, social environment, and occupational domains. The patient had presented with mild alcohol withdrawal at the time of admission including gastrointestinal upset, tremors, headache, and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 4. Patient had alcohol in system as well as cocaine. The patient had a history of substance-related treatment episodes including detoxification and rehabilitation treatment with relapses.  There were no acute medical issues, but was in treatment for coronary artery disease with a stent, congestive heart failure, automatic implantable cardioverter defibrillator (AICD) implant, dyslipidemia, hypertension, and chronic kidney disease, as well as pre-diabetes. The patient was tobacco dependent at one pack per day. There was a history of shoulder and back surgery. Physical examination, laboratory assessment, Chest X-Ray, and electrocardiogram (EKG) were consistent with history of cardio-metabolic disease including elevated liver functions and evidence for alcoholic liver disease. The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a five-day Librium taper, vitamin replacement therapy, fluid replacement, and medical monitoring; the patient was offered smoking cessation treatment and nicotine replacement. Cardiology consultation was obtained with ongoing management of general medical and cardiac conditions. The patient was discharged to a rehabilitation treatment facility with recommendations for clinically appropriate aftercare, as well as recommendation for involvement in 12-step recovery meetings with Alcoholic Anonymous (AA) and follow up with community providers of mental health and primary and cardiology care. The patient in this case presented with a diagnosis of severe alcohol and stimulant use disorder. The patient also has history of general medical and cardiac conditions with associated treatments and alcoholic liver disease, as noted in the clinical summary.
The presenting clinical features and history and risk for withdrawal seizures and general medical complications, and the multiple psychosocial complications of alcohol and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario. Withdraw symptoms were managed and averted with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin replacement therapy. Thus, 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 the substances of abuse if detoxification and treatment were to be attempted at a lower level of care. This answer is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below, and is also consistent with New York State instruction concerning medical necessity reviews including the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines that indicated the necessity and appropriateness of the inpatient level treatment in this case.