Appeal type: Medical necessity
Decision: Upheld


The patient has multiple substance use disorders (alcohol, cocaine, marijuana) and was admitted to an inpatient detox unit. The Credentialed Alcoholism and Substance Abuse Counselor (CASAC) notes documented that she had an open ACS case and was mandated to substance use disorder (SUD) treatment. On presentation she reported daily use of alcohol, drinking half a pint of liquor and 12 beers on a typical day. Her last drink was one 24 oz beer plus "nips" of liquor. She used marijuana daily reporting typical use of three "puffs" at night. However, her last use was a whole "blunt". She used $50 of cocaine three times a week. Her urine was positive for cocaine and tetrahydrocannabinol (THC) and her blood was negative for alcohol. The admitting nurse and nurse practitioner (NP) noted she complained of tremors, anxiety, urges and teary eyes. The NP noted she had bilateral hand tremors. Her pulse was 78 and her blood pressure was 123/74. Her Clinical Institute Withdrawal Assessment (CIWA) was recorded as 11. She did not report using opiates but a Clinical Opiate Withdrawal Scale (COWS) was completed and was 10 at the same time.
The admission Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) completed by the facility recorded that she was incapacitated by use, had a lack of support for early recovery, was at risk of moderate withdrawal, and was not appropriate for outpatient detox programs.
She denied any psychiatric history and denied any history mental health treatment, admission or suicidal thinking. She has been using drugs and alcohol since she was a teen. She has a history of legal involvement related to her SUD along with past medical consequences related to her SUD. She has a history of physical trauma (car accident, head injury, back injury, jaw fracture) in the past and asthma. She was admitted to the detox unit and placed on a five-day Librium taper. She did not require any additional treatment for withdrawal beyond the scheduled Librium taper. A nursing note recorded that she complained of mild hand tremors and anxiety, but her vitals were normal. She twice had a mildly elevated pulse (1001 and 103) and once had an elevated blood pressure reading of 150/89. However, at the time her CIWA was repeated it was with a score of one. Nursing notes do not note any distress or any complaints of withdrawal symptoms. The health plan's determination is upheld in whole. No, the requested health service/treatment of Inpatient Hospital Stay is not medically necessary for this patient. There is mention of untreated mental health conditions, but this is not explained in the chart. She denied serious mental health complaints on admission and did not have any significant behavioral issues during her stay. She is young and generally physically healthy. She has no history of seizures or serious withdrawal. While she is homeless, temporary shelter would be available to her in the state of NY. The CASAC working with her recorded that she had sober support from her family and friends. She has experienced multiple serious consequences for her ongoing use and does have a SUD including significant tolerance and continued use despite these negative consequences. However, the documentation submitted does not support that she required inpatient level of care for her detoxification. She complained of some mild anxiety and tremor, but her vital signs were normal. No CIWA was documented and there is no physician or NP note from that day. She twice had a mildly elevated pulse and once had an elevated blood pressure reading. However, the only CIWA from that day was recorded as a score of one. And, there are no NP or physician notes from that day. In other words, there is no documentation that she was being reevaluated or that there was active medical decision making occurring surrounding her need for the current level of care. A progress note from an NP or physician would be expected to have addressed the changes in her vital signs that day and interpreted them in light of a CIWA of 1 from the same day. In absence of such documentation there is not sufficient clinical evidence that she was at significant risk of withdrawal if not continued at an inpatient level of care. The submitted documentation does not support this level of care for these dates of service.