Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol Abuse.
Treatment:  Inpatient detoxification treatment.

The insurer denied inpatient detoxification treatment.  The determination is overturned.

The patient self-referred and presented to the emergency department with a request for detoxification treatment prompted by health concerns, psychosocial stress, impairment of functioning and complaints related to alcohol withdrawal.  The patient was medically screened and admitted to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol use disorder.  The patient reported daily use of alcohol with up to one and one-half gallons of vodka daily.  She had multiple past treatment episodes including rehabilitation services and detoxification treatments with relapses and inability to abstain due to intense craving and co-occurring psychiatric disorders and severe psychosocial stressors that were triggering his use.  Her more recent substance use disorder treatment had occurred one month prior to admission with immediate relapse.  Her presentation was complicated by multiple general medical problems and falls with the more recent resulting in facial injury with bruising.  Additionally, the patient has a history of withdrawal seizures.

The patient has a history of co-occurring anxiety and depressive disorders.  She denied history of psychiatric hospitalization, and she was not regularly taking her prescribed psychotropic medications but received mental health services with use of Prozac and Gabapentin.  The patient is single with no children and is unemployed and homeless.  She did not have legal issues.  Psychosocial stressors included primary support, occupational and social environment domains.

General medical issues included chronic conditions that included hypertension, dyslipidemia, hypothyroidism, chronic obstructive pulmonary disease (COPD) with asthma, as well as the history of deep vein thrombosis and small bowel obstruction and the frequent falls and withdrawal seizures.  Her medical screening including laboratory assessments that showed electrolyte abnormality with hypokalemia requiring replacement.  A drug screen was positive for cocaine and benzodiazepine and blood alcohol level was at 132.  She was tobacco dependent at one-fourth pack per day.  Her Clinical Institute Withdrawal Assessment (CIWA) scale score was moderately severe at 13.  Withdrawal symptoms included tremor/shakes, nausea, sweats, headache and body aches, anxiety, irritability and insomnia.  She reported intense craving.

The mental status examination revealed an alert and cooperative female with good eye contact and disheveled appearance.  Speech was clear and fluent with linear and logical thought processing and no evidence for psychosis, though she reported intermittent hallucinations.  Mood was dysphoric with anxiety and irritability.  She did not have severe symptoms such as mania, severe cognitive impairment, perceptual disturbances or suicidal ideation.  Insight was limited and judgment impaired. Somatic complaints included the insomnia and gastrointestinal complaints, as well as the frequent falls and an unsteady gait, and dyspnea on exertion.

The patient was admitted to inpatient level care and placed on a detoxification regimen with a Librium taper, as needed (prn) dosing of trazodone and Vistaril, vitamin and nicotine replacement therapy, fluid and electrolyte replacement, and medical monitoring.  Following his first two days of treatment, the patient began to feel better and began to participate in counseling and educational sessions, as well as meetings with the case manager in order to address aftercare.  Going forward, vitamins were continued, as well as comfort medications together with Lopressor, lisinopril, Lipitor, apixaban, and levothyroxine, and the availability of a rescue inhaler.  She was prescribed Keppra and Topamax for seizure prophylaxis and gabapentin and Campral to address craving with plans for continuation for medication assisted treatment.  The patient was continued on a detoxification protocol with monitoring and assistance with daily activities.  As the patient stabilized, she was discharged from detoxification treatment and immediately referred to inpatient residential rehabilitation services with recommendations for clinically appropriate aftercare, as well as recommendations for involvement in 12-step recovery meetings with Alcoholic Anonymous (AA) and follow up with his mental health and primary care clinicians.

The health plan documents including case notes, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's the rationale for the denial of certification for coverage of the requested treatment were reviewed.  The case records and case summary were reviewed.  This review is a New York State mandated review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines. 

The issue under review is inpatient admission and continued stay for detoxification treatment.

The proposed inpatient services and detoxification treatment for severe alcohol use disorder could not have been safely and effectively provided at a lower level of care.  The inpatient treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms and abnormal vital signs and electrolytes in the context of multiple medical problems and high risk for falls and withdrawal seizures.  Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin replacement therapy.  Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.  This answer is consistent the application of NY State OASAS LOCADTR 3.0 Criteria and Guidelines, referenced below.