Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male requesting detoxification treatment and admitted to acute inpatient level care in order to address substance use disorder with alcohol, as well as reported use of stimulant (methamphetamine), opioid (prescription opiates), and sedative-hypnotic-anxiolytic (benzodiazepine) class drugs of abuse. The patient had been using up to two pints of liquor daily. He had a history of at least three prior detoxification and substance use disorder treatments with relapses. His self-referral for treatment was prompted by multiple stressors including housing, occupational, social environment and other psychosocial domains.

The patient has no history of psychiatric disorder and denied psychiatric hospitalization or suicidal or self-harming behavior. He was diagnosed with unspecified or substance-induced depression at the time of presentation.

The patient's evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for treatment and described as cooperative with a full range of affect with apprehension, nervousness, tension, irritability, sleep disturbance, and mild symptoms or alcohol withdrawal. Mood was depressed. Speech was clear with organized thoughts that were free of delusions. There was no evidence for a thought disorder, mania, psychosis or cognitive impairment. The patient denied suicidal or homicidal ideation. Insight was limited with impaired judgment and fair control of impulses. His onset of withdrawal symptoms included anxiety, irritability, insomnia, agitation, nausea and tremor.

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a Librium protocol and prn (as needed) medications for comfort, as well as vitamin and nicotine replacement therapy. The program provided for case management with referral to sober housing and access to rehabilitation treatment that included comprehensive evidence-based treatments. During detoxification the patient engaged in counseling sessions focusing on education about the disease model of addiction, and involvement with counseling and milieu activities including peer support and educational sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained normal during his brief stay.

The patient engaged with detoxification treatment. Withdrawal symptoms remained mild, but persisted with nausea, mild tremor, anxiety and insomnia requiring prn medications and monitoring. The patient was discharged with plans for immediate outpatient level aftercare and recommendations for involvement in peer-supported recovery groups.

Yes, the inpatient substance use disorder treatment with detoxification and withdrawal management and other medical services was medically necessary for this patient.

The requested inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using alcohol on a daily continuous basis with use of other substances of abuse that did warrant inpatient level detoxification and withdrawal management and monitoring for the duration of the protocol; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. The patient's social environment was not conducive to detoxification in the context of limited insight, impaired judgment and only fair control of impulses including a history of relapses with past substance use disorder treatments. The patient was at risk for alcohol withdrawal seizures or encephalopathy requiring inpatient level monitoring and supports.

Thus, this patient's substance use disorder did warrant the admission and the continued structure of an inpatient level detoxification setting with 24-hour monitoring and use of prn medications. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature referenced below, and in keeping with New York State instruction for medical necessity reviews including the appropriate application of the New York State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care determination) Tool that requires the patient in this scenario default to the higher level of care.