Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient presented to the emergency department and was admitted to acute inpatient level services for detoxification and withdrawal management of alcohol and cannabis use disorders. He was using one-half gallon of vodka per day together with $10 worth of marijuana per day and had a long history of substance use that had progressed to the current frequency and quantity of use for the past two years. He had experienced functional impairments and had severe psychosocial stress in the primary support, occupational, economic, housing and legal domains.
The patient had no history of blackouts, withdrawal seizures or delirium tremens. He had no acute general medical issues. He was nicotine dependent with two packs per day use. There was no history of a psychiatric disorder or treatment or a history of suicidal or self-harming behavior.
The patient was admitted following medical screening and placed on a detoxification regimen with as needed (prn) use of Librium, vitamin and nicotine replacement, and medical monitoring. Withdrawal symptoms included sweats, tremor, nausea, anxiety, restlessness, and craving. His withdrawal symptoms peaked and diminished by day two of his stay. Vitamins and nicotine replacement were continued as well as comfort medications and monitoring, and assistance with daily activities. He was maintained on fall and seizure precautions. Withdrawal symptoms were mild with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 5 or less.
The patient remained functional throughout the hospital course and was better able to perform basic activities of daily living with resolution of his withdrawal symptoms. He was provided education and counseling with regard to subsequent care and met with the case manager to address stressors that included primary support (family problems), employment and financial, housing and other psychosocial domains. The patient completed detoxification treatment and was discharged with referral for clinically appropriate aftercare to include residential substance use disorder treatment and recommendations for involvement in 12-step recovery groups with the obtainment of a sponsor.
The issue under review is inpatient substance abuse services.
The requested health service/treatment of inpatient substance abuse services was medically necessary.
The proposed inpatient services could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders and associated and severe psychosocial stressors did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder. Withdrawal symptoms were managed with the use of a benzodiazepine requiring monitoring and other as needed (prn) medications, as well as vitamin and nicotine replacement therapy. 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 alcohol or cannabis if detoxification treatment were to be attempted at a lower level of care. Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer is also consistent with the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.