Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient
The insurer denied: Inpatient substance abuse services
The denial is: Upheld in whole

The patient is a male who presented to the emergency department with a request for detoxification services. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 3 reflecting minimal or light withdrawal symptoms. He has a history of bipolar disorder treated with Zyprexa and Zoloft. He had received multiple past substance use disorder treatments. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. He was medically screened and admitted for inpatient level detoxification with plans for a five-day detoxification treatment episode with Librium, vitamin replacement therapy and comfort medications, as well as resumption/continuation of his usual psychotropic medications. His laboratory assessment and electrocardiogram (EKG) were unremarkable, and his drug screen was positive for cocaine and cannabis and benzodiazepine consistent with history including residual benzodiazepine from recent detoxification. Mental Status Examination. The patient was cooperative with good eye contact. Speech clear and thought production linear and logical. No severe symptoms on mental status examination such as cognitive impairment, severe mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. He presented with minimal withdrawal symptoms. He had limited insight, impaired judgment and poor to fair control of his impulses. He reported decreased appetite and sleep disturbance and fatigue with malaise. The patient is single, homeless and unemployed, and living in a shelter. There was no report of current legal issues. The patient was admitted on for inpatient detoxification treatment with withdrawal management and monitoring. The patient's hospital course progressed without incident. The patient slept and received meals. His monitoring occurred without incident, and he attended groups sessions and received counseling with recommendation for clinically appropriate aftercare. He was compliant with treatment, and progress notes indicate that he was social with peers and had no apparent distress during his stay. He tolerated the taper of Librium and was placed on Zoloft and Zyprexa. He was discharged upon completion of the detoxification treatment and was referred to rehabilitation substance use disorder treatment. The requested health treatment of inpatient substance abuse services is not medically necessary for this patient. Treatment could have been safely and effectively provided with lower level services. The patient was using alcohol on a near-continuous daily basis with intermittent use of cocaine and daily use of marijuana. There were no co-morbid general medical problems or co-occurring psychiatric disorders warranting admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Additionally, the patient had just completed a detoxification treatment episode. Thus, medical necessity is not met for the requested benefit of an admission and continued inpatient detoxification treatment in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria, scientific literature, and Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines and Criteria referenced.