Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse/Addiction
Treatment: Inpatient Substance Abuse Admission
The health plan denied the requested Inpatient Substance Abuse Admission as not medically necessary. 
The health plan's determination is upheld.

The case involves an adult female with admission to inpatient rehabilitation and substance use disorder treatment to address substance use with alcohol, as well as comorbid hypertension with persistently elevated blood pressure that was being treated. The submitted documentation did not report history of blackouts or withdrawal seizures or delirium tremens.
The patient had no co-occurring psychiatric disorders and there was no report of psychiatric hospitalization or suicidal behavior. The patient had declined in her functioning including poor nutrition and meal preparation with weight loss.
The patient had no acute general medical issues; she had hypertension with poorly controlled blood pressure.
The patient lives alone. There were no reported legal issues and no mention of trauma history.
Evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight and coping skills. She did not report suicidal ideation or aggressive impulses. There were no withdrawal symptoms, but her blood pressure was elevated, as noted.
Upon admission to inpatient level services, the patient received a comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with attention to cognitive and behavioral patterns contributing to the alcohol use disorder. Psychiatric evaluation had been provided and affirmed that the patient had no co-occurring psychiatric disorders as a focus of treatment. She was prescribed her usual medication for hypertension, as well as medication assisted treatment with monitoring.
The patient engaged in substance disorder rehabilitation treatment. She received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring and plans for clinically appropriate aftercare, as well as medication assisted treatment of the alcohol use disorder. Her inpatient stay continued through discharge.

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

The requested health service/treatment of Inpatient Substance Abuse Admission was not medically necessary for this patient.
The patient's admission and continued inpatient stay could have been safely provided at an alternate level of care in this case scenario.
The patient in this case presented with alcohol use disorder and comorbid hypertension with elevated blood pressure; she did not experience other general medical complications or present with severe symptoms of a co-occurring psychiatric disorder, or severe withdrawal symptoms that would have warranted inpatient level services and monitoring. Her risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and she did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as indicated in the health plan's denial determination which included the application of NY State OASAS (Office of Addiction Services and Supports) LOCADTR (Level of Care Determination) Criteria/Guidelines.

Thus, the inpatient admission for substance-related rehabilitation treatment and monitoring, and the requested inpatient level services were not clinically appropriate or medically necessary in this case scenario. And any indicated treatment for alcohol use disorder and comorbidities in this case could have been provided, as clinically appropriate, at an alternate of care, as the health plan asserted.