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 male who was admitted for detoxification services for alcohol use disorder. The patient was using alcohol on a continuous daily basis with up to two pints of liquor and three 24-ounce beers, and use of $50 worth of crack cocaine approximately three times per week. He presented with mild symptoms of withdrawal in the context of the alcohol use disorder with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of 9/67. The patient has a history of multiple prior detoxification treatments with relapse. Onset of alcohol use was in adolescence with escalation of use and progression of the disease, and subsequent use of cocaine.

The patient had no history of co-occurring psychiatric disorder or history of suicidal behavior. Chronic medical conditions included gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD) with asthma in the context of tobacco dependence. He was purified protein derivative (PPD) (tuberculosis) positive with a negative chest x-ray. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.

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 for continued substance use disorder treatment with clinically appropriate aftercare. Progress notes indicated that the patient was in no apparent distress and generally calm, but anxious during his inpatient stay. He engaged in treatment and tolerated the Librium taper with vitamin replacement and comfort medications. He was noted to be sleeping and eating okay with no biomedical complications during his stay. At the time of discharge, the patient declined transfer for rehabilitation services, indicating that he would return to outpatient services for aftercare.

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

The denial 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) Criteria 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. 

The appeal 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) Guidelines, indicating that the detoxification was medically necessary and that the patient was at risk for moderate withdrawal had no sober supports.

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 treatment in the past with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and reasonable motivation and was in no apparent distress throughout his inpatient stay. 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 published guidelines, the scientific literature, and 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. 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.