Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol use disorder.
Treatment: Inpatient Detoxification Admission.
The insurer denied the Inpatient Detoxification Admission.
The denial is upheld.

The patient is an adult male, who was admitted for detoxification services for alcohol use disorder. The patient was using alcohol on a continuous daily basis with up to one case of beer per day, and daily use of $20 worth of cocaine with smoking. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with a Clinical Opiate Withdrawal Scale (COWS) score of eight. The patient has a history of prior detoxification and substance use disorder treatment including records that were submitted for a prior treatment episode. Onset of alcohol use was during adolescence with escalation of use and progression of the disease, and use of cocaine beginning in adulthood.

The patient was admitted for inpatient detoxification. The patient's hospital course progressed without incident, and, he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare. He completed the detoxification treatment and was referred and transitioned for continued substance use disorder rehabilitation treatment with clinically appropriate aftercare.

The issue under review is the inpatient admission with detoxification treatment and withdrawal management.

The denial reason was on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guideline indicating that inpatient level treatment was not medically necessary as there were no biomedical or psychiatric concerns or complicated withdrawal in the case, and that the patient was motivated for treatment. 

Appeal: The appeal was on the basis of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines indicating that the detoxification was medically necessary and that guidelines did not require medical instability or psychiatric safety issues or severe psychiatric symptoms in order to be eligible for inpatient detoxification and other medical services. The appeal referenced the risk for increasing symptoms of withdrawal and the medical necessity for the inpatient level detoxification treatment.

No, based on the submitted information, the proposed treatment, inpatient admission, was not medically necessary for this patient.
The proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care, as the denial determination asserts. The 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 ongoing substance use disorder with alcohol, cocaine and tobacco. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, 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 received detoxification and substance use disorder treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and reasonable motivation with fair insight, and a working knowledge of substance use disorder treatment with past treatment, as noted. Thus, the inpatient admission for detoxification treatment and 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 Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and the American Society of Addiction Medicine (ASAM) Criteria, as referenced below.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
In this case scenario, the patient was amenable to treatment with lower-level care in a less restrictive setting, for example, residential level treatment was suggested in the denial determination. The patient displayed no serious disturbance of mental status and no general medical complications or symptoms of co-occurring disorders that would have warranted inpatient level services. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. And, New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.