Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse detoxification, history of unspecified bipolar disorder with depressive episodes and posttraumatic stress disorder (PTSD)
Treatment: Inpatient substance abuse treatment
The insurer denied the inpatient substance abuse treatment. 
The denial is upheld.

The patient is a male. He presented with a request for detoxification services. The patient was using alcohol on a continuous daily basis with approximately one pint of vodka and two six-packs of beer, together with use of two grams of cocaine and up to twelve bags of heroin with inhalation. He was using up to 12 mg of Xanax and marijuana with four blunts per day. He was also participating in a methadone maintenance treatment program (MMTP) with a daily dose of 40 mg. He was diagnosed with poly-substance use with opioid, stimulant, alcohol, cannabis and sedative-hypnotic-anxiolytic class substances.

The patient has a history of unspecified bipolar disorder with depressive episodes and posttraumatic stress disorder (PTSD) and no current treatment or psychotropic medications. 

The patient had received multiple past substance use disorder treatments with detoxification but little or no treatment with rehabilitation due to declining aftercare. 

The patient had no acute general medical problem or significant chronic medical issues. He had snorted a pen tip that required removal, and he was known to be HIV and hepatitis C and B positive. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms. He was tobacco dependent. 

The patient 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 continued use of methadone at the confirmed dose of 40 mg daily.

On Mental Status Examination, the patient was cooperative, groomed and casually dressed with good eye contact. Speech was clear and thought production was linear and logical. There were no severe symptoms on mental status examination such as thought disorder, cognitive impairment, severe mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. He presented with moderate symptoms of withdrawal including nausea, sweats, yawning, and tremor, and he reported insomnia and low energy, but no other somatic complaints or symptoms reflecting drug or alcohol withdrawal symptoms.
The patient is single, homeless and housed, and unemployed. There was no report of current legal issues, but unspecified trauma history with a diagnosis of PTSD.

The patient was admitted on for inpatient detoxification and withdrawal management. The patient's brief 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 with recommendation for clinically appropriate aftercare. 

The patient was discharged against medical advice and declined to proceed directly to rehabilitation substance use disorder treatment. He was advised to attend 12-step recovery groups and proceed to rehabilitation treatment when ready.

The proposed 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. The acute inpatient 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 bipolar disorder and PTSD and despite ongoing active substance use disorders. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk for self-harm, 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 knowledge of substance use disorder treatment protocols- as he was participating in a methadone treatment program for opioid use disorder. The patient had fair insight and control of impulses, and the working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, admission for detoxification treatment with 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.