Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Detoxification Admission.
The insurer denied the Inpatient Detoxification Admission.
The denial is upheld.

The patient is a male who was noted to have been admitted to a medically
monitored intensive inpatient detoxification level of care. He was noted to have
been diagnosed with substance use disorders including alcohol, stimulants and
opioids. The patient was reported to have been admitted for detoxification from
alcohol and opioids. The acute inpatient detoxification level of care was noted to
have been previously denied as not medically necessary.

The patient was provided with individual, group, and milieu therapy, in addition to
medication management while at the inpatient detoxification level of care. He was
noted to have been prescribed methadone, in addition to medications for use as
needed in any ongoing medical conditions. The patient was noted to have been
placed on opioid withdrawal protocol. There was no indication that the patient had
any adverse effects from any prescribed medications.

The patient was not reported to have any significant unstable vital signs or
abnormal biochemical parameters at the time of his admission to the inpatient
detoxification level of care. He was not reported to have any significant withdrawal
symptoms at the time of his admission as indicated by elevated scores on
withdrawal rating scales including the Clinical Institute Withdrawal Assessment
Alcohol (CIWA) and Clinical Opiate Withdrawal Scale (COWS). The patient was
reported to have withdrawal symptoms including hot and cold sweats, chills, and
general discomfort. However, there was no indication that the patient had any
significant physiological withdrawal symptoms that required 24 hour medical and
nursing care.

The patient was not reported to have any suicidal or homicidal ideations with plans
or intent. He was not reported to have any symptoms suggestive of psychosis
including command hallucinations, persecutory delusions or extreme paranoia. He
was not reported to have exhibited any significant agitation or aggression at the
time of his admission. The patient had no significant ongoing medical problems that
required hospital-based interventions. He was not reported to have any functional
impairments including activities of daily living and self-care. He was not reported to
have had any significant adverse effects from medications.

No, the proposed treatment (acute inpatient detoxification level of care) was not
found to be medically necessary.

Based on the American Society of Addiction Medicine (ASAM) criteria and current
peer reviewed, evidence-based medical literature, the requested acute inpatient
detoxification level of care for date of service was not found to be medically
necessary. The clinical information provided does not indicate that the acute
inpatient detoxification level of care was the least restrictive setting that was
medically necessary or that would be successful in treating the patient's symptoms.

Based on the ASAM criteria and the clinical information provided, the patient did not meet criteria for medically monitored high intensity inpatient detoxification level of care.

Dimension 1 (Acute intoxication or withdrawal potential): There was no indication of the patient had any acute intoxication or severe withdrawal potential. There was no indication of the patient had any significant physiological withdrawal symptoms or had difficulty tolerating or coping with any withdrawal symptoms. The patient was not noted to have any significant risk for severe withdrawal. Risk Rating - 1
Dimension 2 (Biomedical conditions and complications): The patient was not noted to have any significant comorbid medical conditions that required inpatient treatment. There was no indication of the patient had any significant medical complications related to substance abuse. The patient was not reported have any significant physical discomfort. Risk Rating - 0
Dimension 3 (Emotional, behavioral or cognitive conditions and complications): There was no indication that he had any significant ongoing symptoms of any comorbid psychiatric conditions. The patient was not reported to have any active suicidal or homicidal ideations. There was no indication that the patient had any symptoms of psychosis or mania. The patient was noted to have some mood dysphoria and irritability. However, symptoms were noted to have been largely stable with ongoing interventions.) Risk Rating - 1
Dimension 4 (Readiness to change): The patient was noted to have been engaged and participating in treatment. He was noted to be motivated to remain sober. However, he was noted to have some ambivalence regarding treatment. Risk Rating - 1
Dimension 5 (Relapse, continued use or continued problem potential): The patient was reported to have a history of relapses in the past. He was noted to have some vulnerability related to a history of behavioral health symptoms. However, he was noted to have fair self-management and relapse prevention skills. Risk Rating - 1
Dimension 6 (Recovery/living environment): The patient was noted to have a supportive family and social supports. He was noted to have recent issues with relationships including breakup from his girlfriend. Risk Rating - 1

Therefore, the proposed treatment (acute inpatient detoxification level of care) was not found to be medically necessary. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as a 23-hour observation followed by partial hospitalization program.

Yes, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient may have been treated safely and effectively in a less restrictive setting and lower level of care including a 23-hour observation followed by a partial hospitalization program. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.