Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Detoxification Admission. 

The insurer denied the Inpatient Detoxification Admission. 
The denial is upheld. 

The patient is a male who was admitted to a substance abuse inpatient detoxification level of care. He was diagnosed with substance use disorders including cocaine (F14.20), cannabis (F12.20) and nicotine use disorder (F17.210). The patient was reported to have been admitted for detoxification from substances. He was reported to have social, interpersonal, occupational, financial, and physical health consequences related to substance abuse. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. He was not reported to have any significant ongoing behavioral health symptoms at the time of his admission. 

Clinical information reviewed does not indicate that the patient had any significant ongoing withdrawal symptoms at the time of his admission to the inpatient detoxification level of care. The patient was not reported to have any significant unstable vital signs or abnormal biochemical parameters. He was not reported have any significant physiological withdrawal symptoms at the time of his admission as indicated by elevated scores on withdrawal rating scale such as Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA) or Clinical Opiate Withdrawal Scale (COWS). 

The patient was not reported to have any significant ongoing behavioral health symptoms. He was not reported to have any suicidal or homicidal ideations with plans or intent. There was no indication of the patient was at imminent risk of harm to himself or others. The patient was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have any functional impairments including activities of daily living and self-care that represented a change from his baseline. 

There was no indication that the patient had any significant worsening or emergence of new symptoms throughout his stay at the inpatient detoxification level of care. Clinical information reviewed does not indicate that the patient had any significant barriers to treatment in the community including severe psychosocial stressors, lack of social support or unsafe living environment. 

No, the proposed treatment (substance abuse inpatient detoxification level of care) was not medically necessary. 

Based on current peer-reviewed, evidence-based medical literature, the requested substance abuse inpatient detoxification level of care was not found to be medically necessary. The medical records and accompanying information do not indicate that inpatient detoxification level of care was the least restrictive medical setting that was medically necessary or that would be likely to result in improvements in the patient's symptoms (1-8). 

The patient was not reported to have any significant ongoing behavioral health symptoms. He was not reported to have any suicidal or homicidal ideations with plans or intent. There was no indication of the patient was at imminent risk of harm to himself or others. The patient was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have any functional impairments including activities of daily living and self-care that represented a change from his baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. 

Yes, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient. 

The patient is a male who was admitted to a substance abuse inpatient detoxification level of care. He was diagnosed with substance use disorders including cocaine (F14.20), cannabis (F12.20) and nicotine use disorder (F17.210). The patient was reported to have been admitted for detoxification from substances. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. He was not reported to have any significant ongoing behavioral health symptoms at the time of his admission. The patient was not reported to have any significant withdrawal symptoms from substances that required 24-hour medical and nursing care at the time of his admission. There was no indication that the patient had any unstable vital signs that were abnormal by clinical parameters. He was not reported to have any significant physiological withdrawal symptoms. The patient was not at immediate risk of harm to himself or others. There was no indication of the patient had any significant functional impairments including activities of daily living or self-care that represented a change from his baseline. There was no indication of the patient had any significant barriers to treatment in the community. Therefore, the health plan was noted to have acted reasonably, but sound medical judgment and in the best interest of the patient.