Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Medically Supervised Inpatient Detoxification Services
The insurer denied the medically supervised inpatient detoxification services.
The denial is upheld.

The patient is a male who was admitted to a substance abuse inpatient detoxification level of care. He was diagnosed with substance use disorders including alcohol, benzodiazepines, and cocaine. The patient was reported to have been admitted for detoxification from substances. The patient was reported to have a significant history of substance abuse treatment in the past, including numerous inpatient detoxification admissions. The patient was reported to have social, interpersonal and physical health consequences related to substance abuse. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. He was noted to have a medical history significant for a history of partial colectomy and insomnia.

The patient was provided with individual, group, and milieu therapy, in addition to medication management while at the inpatient detoxification level of care. He was noted to have been placed on an alcohol withdrawal protocol with chlordiazepoxide. There was no indication that the patient was prescribed any other psychotropic medications or medication assisted treatment for substance abuse. The patient was not reported to have any significant adverse effects from any prescribed medications.

The patient was not reported to have any significant withdrawal symptoms at the time of his admission to the inpatient detoxification level of care. There was no indication that the patient had any significant unstable vital signs or abnormal biochemical parameters. He was not reported have any significant physiological withdrawal symptoms at the time of his admission as indicated by elevated scores on withdrawal rating scales including the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA) and Clinical Opiate Withdrawal Scale (COWS). The patient was noted to have scored 10 on the CIWA and 5 on the COWS, indicating mild withdrawal symptoms from alcohol/sedative-hypnotics.

The patient was not reported to have any significant ongoing behavioral health symptoms that required inpatient treatment at the time of his admission. He was not reported to have any suicidal or homicidal ideations with plans or intent. The patient was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions, or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression at the time of his admission. The patient was not reported to have any functional impairments including activities of daily living and self-care that represent a change from his baseline. He was not reported to have had any significant adverse effects from medications. He was noted to have been discharged from the inpatient detoxification level of care.

No, the substance abuse inpatient detoxification level of care was not found to be medically necessary.

Based on current peer-reviewed, evidence-based medical literature, the requested service (medically monitored high intensity inpatient detoxification level of care) was not found to be medically necessary. The clinical information provided does not indicate that the requested service was the least restrictive setting that was medically necessary or that would result in improvement in the patient's symptoms.

Clinical information provided does not indicate that the patient had any significant withdrawal symptoms that required acute inpatient detoxification level of care at the time of his admission. There was no indication that the patient had any significant unstable vital signs are abnormal biochemical parameters. The patient was not reported to have any significant physiological withdrawal symptoms as indicated by elevated scores on standardized withdrawal scales including the CIWA and COWS. There was no indication that the patient had any significant ongoing medical conditions that required hospital-based interventions or monitoring. He was not reported to be at imminent risk of harm to himself or others. There was no indication that the patient had any significant functional impairments including activities of daily living or self-care that represented a change from his baseline. The patient had been treated safely and effectively in a less restrictive setting in a lower level of care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient.