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 female who was admitted to a substance abuse, medically monitored, high intensity, inpatient detoxification level of care. She was diagnosed with substance use disorders including alcohol (F10.220), opioids (F11.20), cocaine (F14.21) and cannabis (F12.21). The patient was reported to have been admitted for detoxification from substances including alcohol and opioids. Urine toxicology screen at the time of her admission was noted to have been positive for opioids, benzodiazepines, and methamphetamines.

The patient was reported to have started abusing alcohol several decades prior. She was reported to have been drinking significant amounts of alcohol for several decades. The patient was reported to have been drinking about two pints of hard liquor daily. She was reported to have last consumed alcohol on the day of her admission. The patient was reported to have started abusing heroin several decades prior. She was reported to have been inhaling up to two bags of heroin a week. The patient was last reported to have used heroin on day of admission. She was reported to have started abusing cannabis several decades prior. She was reported to have used cannabis one to three times over the past 30 days. She was last reported to have used cannabis approximately a month prior to admission. There was no indication that the patient had any significant history of severe withdrawal in the past, including withdrawal seizures, hallucinations, or delirium tremens.

The patient was reported to have a significant history of substance abuse treatment in the past, including inpatient detoxification treatment two other times. She was noted to have a medical history significant for asthma and human immunodeficiency virus (HIV) positive status. Other medical conditions indicated include insomnia and gastroesophageal reflux disease. She was noted to have behavioral health symptoms including anxiety (F41.9) and depression (F32.9).

There was no indication that the patient had any unstable vital signs or abnormal biochemical parameters at the time of her admission. There was no indication that the patient had any significant physiological withdrawal symptoms as indicated by elevated scores on Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA) or the Clinical Opioid Withdrawal Scale (COWS). The patient was noted to have a score of eight on the CIWA at the time of her admission, indicating minimal withdrawal symptoms. She was reported to have mild withdrawal symptoms including anxiety, mild nausea and tremors. 

Clinical information reviewed does not indicate that the patient had any significant ongoing behavioral health symptoms that required inpatient treatment. She was not reported to have any suicidal or homicidal ideations with plans or intent. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions, or extreme paranoia. She was not reported to have exhibited any significant agitation or aggression at the time of her admission. The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. She was not reported to have any functional impairments including activities of daily living and self-care that represented a change from her baseline. She was not reported to have had any significant adverse effects from medications. The patient was noted to have been discharged from the inpatient detoxification level of care.

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

Based on current peer-reviewed, evidence-based medical literature, the requested service (substance abuse inpatient detoxification level of care) was not found to be medically necessary. The clinical information reviewed does not indicate that the requested service was the least restrictive setting that was medically necessary and likely to result in improvement in the patient's symptoms (1-9).

There was no indication that the patient had any unstable vital signs or abnormal biochemical parameters at the time of her admission. There was no indication that the patient had any significant physiological withdrawal symptoms as indicated by elevated scores on the CIWA or the COWS. The patient was noted to have a score of eight on the CIWA at the time of her admission, indicating minimal withdrawal symptoms. She was reported to have mild withdrawal symptoms including anxiety, mild nausea and tremors. 

Clinical information reviewed does not indicate that the patient had any significant ongoing behavioral health symptoms that required inpatient treatment. She was not reported to have any suicidal or homicidal ideations with plans or intent. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. She was not reported to have exhibited any significant agitation or aggression at the time of her admission. The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. She was not reported to have any functional impairments including activities of daily living and self-care that represented a change from her baseline. She was not reported to have had any significant adverse effects from medications. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care.

The patient was not reported to have any significant ongoing symptoms of withdrawal from substances that required a medically monitored, high intensity, inpatient detoxification level of care at the time of her admission. The patient was not reported to have any unstable vital signs or significant abnormalities in biochemical parameters. There was no indication that the patient had any acute or intermediate medical problems that required treatment at an inpatient level of care. She was not deemed to be at risk of harm to self or others. There was no indication that she had any significant ongoing behavioral health symptoms that required treatment at the inpatient level of care. There was no indication that the patient had any significant functional impairments including activities of daily living or self-care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient.