Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Treatment
The insurer denied: Inpatient Detoxification Treatment
The denial is overturned.

The patient is an adult male who presented for detoxification and withdrawal management. The patient has a history of severe substance use disorders with daily use of alcohol and stimulants (cocaine) class substances. At the time of presentation, the patient was feeling unwell and requesting detoxification. The patient provided no past history of withdrawal seizures or delirium tremens but did report severe alcohol withdrawal symptoms and frequent blackouts. He was medically screened and admitted for inpatient level detoxification for a five-day detoxification treatment with Librium and supportive measures. Withdrawal symptoms were moderate with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score of eight and persistent withdrawal symptoms throughout the stay together with elevated blood pressure and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score that increased to ten on day two of the inpatient stay. Medical screening drug screen was positive and consistent with history. The patient displayed limited insight and impaired judgment due to the addictions. He demonstrated symptoms of anxiety with generalized symptoms including insomnia, and anxious affect together with symptoms related to the alcohol and cocaine withdrawal, as noted. He was cooperative with normal speech and linear thought processing. Withdrawal symptoms included the anxiety and restlessness, as well as headache and tremor. The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins, as well as nicotine replacement for tobacco dependence with the availability of counseling and comfort medications and as needed (PRN) medications prescribed for pain, anxiety, and insomnia. Vital signs remained abnormal with blood pressure variability, and the patient reported mild anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished. He was participating in counseling and educational sessions with introduction of 12-step self-help meetings. He was discharged with referral for rehabilitation substance-related treatment. The health plan denied coverage for the requested services 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 the patient could have been provided services with lower-level care. The treatment facility indicated that the requested services were medically necessary in keeping with New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines for the treatment of substance use disorders. 

The requested health service is medically necessary for this patient. 

The patient in this case was using large quantities of alcohol on a daily continuous basis together with cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. The patient was at risk for withdrawal seizures and other complications that did necessitate the 24-hour monitoring and withdrawal management. The patient would not have been able to maintain abstinence if treatment were attempted with lower-level services. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, and New York State instruction for medical necessity reviews including the appropriate application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0. Crite