Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Use Disorder. 
Treatment: Inpatient admission. 
The insurer denied inpatient admission. 
The health plan's determination is upheld. 

The patient is a male who presented with a request for detoxification and substance-related treatment. He reported drinking alcohol in large quantity with up to one and one-half pints use per day and crack cocaine daily. His onset of substance use began in adolescence with continued use and no "clean time." He was medically screened and admitted to inpatient level services for detoxification and withdrawal management, stabilization, and other medical services. 
The patient had no history of withdrawal seizures or delirium tremens or prior history of severe withdrawal from alcohol. His self-referral was prompted by his desire to stop using alcohol due to concerns about his use interfering with his life. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 9 together with normal vital signs. The patient had an extensive history of substance use disorder treatment with multiple detoxification treatment episodes and multiple rehabilitation treatments with relapses. 
There were no acute general medical issues in this case other than bronchitis treated with antibiotics, and no serious psychiatric issues in this case with no history of psychiatric disorder. He reported a history of chronic obstructive pulmonary disease (COPD) with asthma and gastroesophageal reflux disease (GERD) with associated treatments. Laboratory assessment was unremarkable or normal, and drug screen was consistent with history with the presence of cocaine and a blood alcohol level of zero. He was tobacco dependent. 
Mental status examination was free of severe symptoms such as thought disorder, mania, psychosis, cognitive impairment, or perceptual disturbance. The patient was deemed to be motivated to enter detoxification treatment and he had mild symptoms of withdrawal at the time of admission. 
The patient was admitted and placed on a detoxification protocol with tapering doses of Ativan and supportive measures with comfort medications including the use of Vistaril and Benadryl for anxiety and insomnia, as well as vitamin replacement therapy. The patient was discharged with recommendations for clinically appropriate aftercare referral to inpatient rehabilitation substance use disorder treatment which the patient declined indicating that he would return for rehabilitation treatment. 
At issue is the medical necessity of inpatient admission. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. 
The health plan's determination of medical necessity is reasonable and consistent with New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines and with prevailing standards of medical practice in this case scenario. The requested benefit of detoxification treatment and withdrawal management and other medical services could have been safely and effectively provided with lower-level services. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was motivated for detoxification treatment and had access to substance use disorder services in the community.