Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient presented to the emergency department with a request for detoxification treatment. The patient reported nausea and intermittent vomiting of bright red blood together with intractable hiccups. He reported drinking alcohol in a large quantity on a daily basis for the past 25 years. He was medically screened with supportive measures on the emergency department and admitted to inpatient level services for detoxification of alcohol and stabilization and other medical services.
The patient reported using cocaine as well as alcohol. The patient had no history of withdrawal seizures or delirium tremens. His self-referral was prompted by his desire to stop using alcohol due to concerns about his health. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 9-12 with sweats, gastrointestinal upset, headache, tremor, anxiety and restlessness/agitation together with normal vital signs or mildly elevated pulse at 101 and a blood alcohol level of 90.
There were no acute general medical issues other than the report of vomiting and nausea and other symptoms of alcohol withdrawal, and no psychiatric issues in this case with a past history of unspecified anxiety disorder. Laboratory assessment was unremarkable except for elevated liver functions and gamma-glutamyl transferase (GGT), and a urine drug screen that was positive and consistent with history including the presence of cocaine and the blood alcohol level reflecting recent use. He was tobacco dependent.
The mental status examination was free of severe symptoms such as thought disorder, mood disturbance, 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, as noted, as well as the report of intermittent vomiting.
The patient was admitted and placed on a CIWA detoxification regimen with intravenous (IV) Fluids, Ativan, and supportive measures with comfort medications including Zofran, as well as vitamin and nicotine replacement therapy. The detoxification was uncomplicated with regard to withdrawal management in that he was noted to be in no apparent distress on the next day, his liver functions were trending down. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and electrocardiogram (EKG). He had no withdrawal signs or symptoms, and was stable and in distress. He had resumed treatment with his home medications including citalopram, trazodone and as needed (prn) hydroxyzine, as well as methyl prednisone and azathioprine. The patient was discharged with clinically appropriate aftercare and immediate referral to outpatient rehabilitation substance use disorder treatment and recommendation for follow up with his primary care physician (or provider) (PCP).
 
The case records, health plan documents including case notes, appeal documents, correspondence from the health plan and treatment facility, and the rationale for the denial of certification for coverage of the requested services were reviewed. This case is a New York State mandated review with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines.
At issue is the medical necessity of the inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
The requested 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 considered to be motivated for detoxification treatment, and had access to substance use disorder services in the community. The denial determination reasonably indicated that lower-level treatment with an observation level of care with monitoring was an appropriate alternative to inpatient admission and in the best interest of the patient. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature, referenced below, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines, referenced below.