Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence with withdrawal, uncomplicated
Treatment: Inpatient Hospital Admission 
The health plan denied the inpatient hospital admission as not medically necessary.
The health plan's determination is overturned.

The patient is an adult male who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol and stimulants (crack cocaine), and nicotine class substances of abuse. He has a history of multiple detoxification treatment episodes with over ten recent treatment episodes with relapses. He was using 1 pint of liquor plus two packs of beer on a continuous daily basis together with crack cocaine daily.

The patient has a co-occurring psychiatric disorder best characterized as schizophrenia. The patient has comorbid general medical conditions with hepatitis C positivity, asthma, and hypertension. The submitted information provided no history of withdrawal seizures or delirium tremens. Withdrawal symptoms were present with an initial Clinical Institute Withdrawal Assessment (CIWA) scale score of 13.

The patient was admitted for inpatient treatment with the detoxification protocol. CIWA scale scores remained elevated between 13 and 9 up until the time of discharge. The patient's hospital course progressed without incident. The patient decided to leave treatment on day three of the treatment.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of inpatient hospital admission was medically necessary for this patient.

The requested benefit of inpatient detoxification treatment and withdrawal management and monitoring and other medical services is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower-level services, as the appeal indicated.

Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at an alternate level of care following the assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had a history of treatment with relapses. The patient had associated clinical features that included co-occurring psychiatric disorder and general medical comorbidities including hypertension. The adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate 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 abuse (frequency and quantity) and co-occurring psychiatric disorder and medical comorbidity do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications such as seizures, if detoxification and withdrawal management were to be attempted at an alternate level of care.