Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient Substance Abuse Treatment
The insurer denied Inpatient Substance Abuse Treatment.
The denial is upheld. 

No, the proposed treatment, Inpatient Substance Abuse Treatment was not medically necessary for this patient.

The patient is a male who presented with a request for detoxification services. The patient was using alcohol on a continuous daily basis with up of two pints of liquor together with beer, and use of cocaine with approximately $50 worth of crack cocaine per week. The patient has a history of depressive disorder, but was not currently receiving mental health treatment. His substance use began in adolescence with progression of the disease and escalating use over a thirty-year time frame. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. The patient had no acute general medical problems. He was in treatment for hypertension with amlodipine, asthma with Symbicort and albuterol inhaler, hyperthyroidism with methimazole, and general treatment for chronic pain related to osteoarthritis of the hip with history of hip fracture. He was medically screened and admitted for inpatient level detoxification with plans for a detoxification treatment episode with Librium taper, vitamin replacement therapy and comfort medications, as well as continuation of his medications to address hypertension, asthma and hyperthyroidism.

Mental Status Examination: The patient was cooperative with good eye contact. Speech was clear and thought production was linear and logical. There were no severe symptoms on mental status examination such as thought disorder, cognitive impairment, mood disturbance, psychosis or perceptual disturbance, or suicidal ideation. He denied past psychiatric hospitalization. He presented with anxiety/irritability and insomnia. He had fair control of his impulses. He had mild or minimal symptoms reflecting withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of five.

The patient is separated, homeless and living with his uncle, and unemployed. There was no report of current legal issues or trauma history.

The patient was admitted for inpatient detoxification. The patient's hospital course progressed without incident with persistent symptoms of anxiety and mild tremor with steady gait. His mild symptoms of withdrawal had resolved by day #2 of his inpatient stay with a CIWA scale score of zero. The patient slept and received meals. Again, his monitoring occurred without incident, and he had the opportunity to attend group sessions and receive counseling and education with planning for clinically appropriate aftercare. Campral was prescribed to address craving and he required one dose of clonidine in lieu of continued use of Librium. He was discharged with referral for primary care and follow-up for substance use disorder rehabilitation treatment. 

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. 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 and cocaine and history of a co-occurring depressive disorder and general medical issues that were chronic. 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, history of complicated drug or alcohol withdrawal or biomedical issues in this case, as noted in the clinical summary. The patient had fair insight and control of impulses. Thus, 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 OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.