Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse/addiction
Treatment: Substance abuse Inpatient
The insurer denied the Inpatient stay
The health plan's determination is overturned in whole. 

The Inpatient substance abuse stay was medically necessary for this patient. The patient  was admitted to acute inpatient level services for detoxification and withdrawal management of severe alcohol and cannabis use disorders. Patient was using one pint of rum and three to four marijuana blunts per day and had a 24-year history of substance use.
The patient has a past history of detoxification/substance use disorder treatments on multiple occasions with relapses with at least six detoxification treatments the previous year. Patient had no history of blackouts, withdrawal seizures or delirium tremens. The patient presented with no acute general medical issues though patient had chronic conditions that included gastroesophageal reflux disease (GERD) and Seasonal Allergies and was nicotine dependent. Additionally, the patient has a history of bipolar mood disorder and unspecified anxiety with panic attacks and insomnia. Patient was known to be non-compliant with treatment due to  addiction.
The patient's self-referral was prompted by the desire to take better care of  children, and a recent emergency department visit, and one-night observation stay due to aggressive behavior directed toward the daughter's social worker. The patient in this case presented with a diagnosis of severe alcohol and cannabis (marijuana) use with an exacerbation of mood disorder that had required emergency services prior to  referral for detoxification treatment. The patient has history of multiple past treatment episodes with relapses and co-occurring bipolar mood disorder and unspecified anxiety disorder with recent non-compliance with mental health follow up and non-adherence of psychotropic medication regimen.
The presenting clinical features and history, and risk for withdrawal seizures and other complications of alcohol and cannabis use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively provided at a lower level of care in this case scenario. The adult inpatient treatment of this patient's substance use disorders, co-occurring psychiatric disorders, and severe psychosocial stressors did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorder, and the continued presence of symptoms related to co-occurring psychiatric disorders requiring treatment.
Withdrawal symptoms were managed with tapering dosages of benzodiazepine requiring monitoring and as needed  medications, as well as comfort medications, and medications to address the craving and insomnia. The patient's history of alcohol and marijuana use (frequency and quantity) and co-occurring mood and anxiety disorders do reflect the seriousness of this case such that an inpatient setting was necessary. 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 marijuana if detoxification and treatment were to be attempted at a lower level of care.