Appeal type: Medical necessity
Decision: Upheld

The patient is a transgender male to female who self-referred and was requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with up to six times 24 ounces of beer together with crack cocaine and cannabis intermittently. She had a 33 year history of alcohol use beginning in adolescence. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms; vital signs were normal, and the Clinical Institute Withdrawal Assessment (CIWA) scale score was 12 with mild symptoms including sweats, mild tremor and reports of nausea, irritability and anxiety. The urine drug screen was positive for benzodiazepine and tetrahydrocannabinol (THC) and the blood alcohol level was .064 at the time of presentation. There was no reported use of other illicit drugs or other drugs of abuse. The patient was tobacco dependent. There were no general medical issues in this case. She was medically screened and cleared for admission to detoxification treatment.

The patient was admitted for inpatient detoxification and other medical services following the assessment for safety issues and medical clearance. She received vitamin replacement therapy, and other supportive measures including as needed (prn) Benadryl and Vistaril for insomnia and anxiety, as well as clonidine. The patient's hospital course progressed without incident. She was placed on a Librium taper over a five day time frame. The patient slept and received meals without complications. Her gait was normal and there was no evidence for severe withdrawal symptoms. Her monitoring occurred without incident throughout the inpatient stay with resolution of withdrawal symptoms by day three of the detoxification treatment episode. The patient had received counseling with recommendations for clinically appropriate aftercare including involvement with counseling and educational groups. She was discharged with completion of the detoxification treatment and declined immediate transfer for rehabilitation services and was provided a referral for clinically appropriate aftercare and rehabilitation substance-related treatment at a later time.

The health plan's determination is upheld.

The requested health service/treatment of the continued Inpatient Services was not medically necessary for this patient.
The continued inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the continued 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 other substances of abuse. Moreover, the patient had been evaluated and cleared with regard to safety concerns and general medical conditions in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted the continued inpatient level treatment.
Thus, the detoxification treatment and 24-hour monitoring, and the requested inpatient level services for the time interval under review were not medically necessary in this case. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care.