Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse.
Treatment: Medically Supervised Inpatient Detoxification.
The insurer denied: Medically Supervised Inpatient Detoxification.
The denial is upheld.

The patient is an adult male who presented for detoxification and withdrawal management for opioid (heroin), crack cocaine, alcohol and cannabis class substances of abuse. He presented with a blood alcohol level of zero and mild symptoms of withdrawal with tremors, anxiety and intense cravings. He had received past substance use disorder treatments including the recent detoxification 4 months ago. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms. The patient had a history of psychiatric disorders and past treatment for anxiety and depression. He had no acute general medical problems; he was tobacco dependent at one-fourth pack per day. His substance use included up to five to six bags of heroin and two pints of alcohol (cognac) per day and intermittent use of crack cocaine and cannabis. The patient was medically screened and admitted for inpatient level detoxification with use of Suboxone, vitamin replacement therapy and comfort medications. His drug screen was positive for cocaine, tetrahydrocannabinol (THC), benzodiazepines and opiates. Mental Status Examination: There were no severe symptoms on mental status examination. He presented with anxiety/irritability and complaints of insomnia. He had fair control of his impulses. He reported tremors but no other somatic complaints. The patient's hospital course progressed without incident. Vital signs were consistently normal, and the patient was in no apparent distress. The patient slept with the use of mirtazapine and gabapentin. He was discharged against medical advice 2 days later with referral back to his outpatient clinic and recommendations to resume his involvement with 12-step recovery groups and continued use of Suboxone.

The denial was based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria. The denial determination indicated that the patient could have been treated with lower-level services such as residential care. 

The appeal was on the basis of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that the patient had deficient coping skills and warranted inpatient level services.

The proposed treatment, inpatient substance abuse treatment was not medically necessary for this patient. 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 acute inpatient treatment of this patient's substance use disorder did not warrant 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. There was no co-occurring psychiatric disorder or psychiatric symptoms that would have warranted inpatient level treatment. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of treatment. Thus, an inpatient admission for detoxification treatment was not medically necessary in this case scenario.