Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Substance Abuse Rehabilitation Services. 
 
The insurer denied Inpatient Substance Abuse Rehabilitation Services. 
The denial is upheld. 

The patient is a adult male. He presented to the emergency department with a request for detoxification services. The patient was using alcohol on a continuous daily basis with up of two pints of liquor plus beer, and use of cannabis with daily use of 1-2 marijuana joints. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder. He had a positive drug screen for PCP (phenylcyclohexyl piperidine) and cannabis. The patient has a history of detoxification treatments including a recent treatment episode six months prior to presentation. 

The patient had a history of a co-occurring anxiety disorder and denied past history of suicidal or self-harming behavior. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms, but did report history of blackouts. The patient had no acute general medical problems. He had low back pain treated with Robaxin and Tylenol. He was tobacco dependent. 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 the availability of nicotine replacement therapy. Laboratory assessment showed a slightly low hematocrit and was otherwise unremarkable. EKG (electrocardiogram) and chest X-Ray were normal. 

The patient was admitted for inpatient detoxification. He was placed on a Librium taper with vitamin therapy and comfort medications as noted. He received counseling and education and motivational enhancement therapy, and had the opportunity to participate in recovery groups. He was placed on Campral for medication assisted treatment. The patient's hospital course progressed without incident. The patient slept and received meals. His monitoring occurred without incident, and he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare. 

His CIWA (clinical institute withdrawal assessment) scale increased from 1 to 2. Thereafter, he refused Librium and continued to have mild withdrawal symptoms. He completed the detoxification treatment and was discharged. He was advised on further treatment as clinically appropriate. 

The requested inpatient treatment was considered by the health plan as not medically necessary under the plan in keeping with LOCADTR (level of care for alcohol and drug treatment referral) 3 Guidelines. The health plan recommended rehabilitation treatment in a residential treatment setting. 

The treatment facility appealed the denial on the basis that the patient had immediately relapsed after his last detoxification treatment episode, and had severe withdrawal symptoms. The appeal also noted that the patient was not appropriate for outpatient level detoxification treatment. 

No, the Inpatient Substance Abuse Rehabilitation Services was not medically necessary.
The inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care, as the health plan asserts. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cannabis and a comorbid anxiety disorder. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past treatment, as noted. 

Thus, the inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario, contrary to the appeal from the treatment facility that argued that the patient had immediately relapsed after his last detoxification treatment episode, and had severe withdrawal symptoms. The appeal also noted that the patient was not appropriate for outpatient level detoxification treatment; the health plan indicated that the appropriate level of care was residential treatment per LOCADTR (level of care for alcohol and drug treatment referral) 3 Guidelines. 

This answer is consistent with New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM (American Society of Addiction Medicine) Criteria, as referenced below. 

The health plan reasonably asserted that the requested inpatient treatment was considered not medically necessary under the plan in keeping with LOCADTR (level of care for alcohol and drug treatment referral) 3 Guidelines. The health plan appropriately recommended rehabilitation treatment in a residential treatment setting. In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.