Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient admission/inpatient substance abuse services.
The insurer denied the inpatient admission/inpatient substance abuse services.
The health plan's determination is upheld.

The patient is a male who presented for inpatient substance related services. The patient was using cannabis on a continuous daily basis with approximately five joints daily together with intermittent use of $20 worth of cocaine with snorting. He had a long standing history of substance use beginning in adolescence and had little or no substance use disorder treatment and has no history of achieving sobriety. He was not in active substance use disorder treatment or involved with 12 step recovery groups.
The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms. The patient's vital signs were normal with a normal or unremarkable laboratory assessment and a positive drug screen consistent with his history. He was tobacco dependent at two packs per day for 15 years.
There was psychiatric comorbidity in this case best characterized as unspecified depressive disorder and post-traumatic stress disorder (PTSD) related to police brutality 15 years prior with hospitalization. The patient denied current mental health treatment or recent psychiatric hospitalization or suicidal behavior. The patient's mental status examination revealed mild symptoms of anxiety and insomnia with no severe symptoms and limited insight and judgment. He exhibited withdrawal symptoms including tremors, anxiety, irritability and craving.

The patient was admitted for inpatient detoxification, withdrawal management and substance-related services with as needed (prn) use of Vistaril and comfort medications and other medical services following the assessment for safety issues and medical clearance. He received vitamin replacement therapy and other supportive measures.
The patient's hospital course progressed without incident. The patient slept and received meals without complications. His gait was normal and there was no evidence of severe withdrawal symptoms. His monitoring occurred without incident throughout the inpatient stay. The patient was feeling better on the day following his admission. The patient had received counseling with a recommendation for clinically appropriate aftercare. He became disgruntled and left against medical advice. His discharge diagnoses included the substance related disorders with the stimulants (cocaine) and cannabis (marijuana) and the co-occurring PTSD and depressive disorder. There were no biomedical or psychiatric issues during his stay and he was euthymic and cooperative with care up until his discharge date.

The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could have been safely provided at a lower level of care.
The patient in this case presented with continuous daily use of cannabis/marijuana and intermittent use of cocaine; he did not experience serious complications or present with severe symptoms of a co-occurring psychiatric disorder/depressive disorder, or abnormal findings on examination, or severe withdrawal symptoms, as noted in the clinical summary. His risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and he did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested.

The requested health service and treatment of the inpatient admission was not medically necessary for this patient.
The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder and history of an unspecified depressive disorder and PTSD.