The patient had a history of multiple substance use disorders (alcohol, sedatives, opioids) who received medically supervised withdrawal services. The patient had last use heroin, alcohol, and benzodiazepines. The patient was reported to have been using 8 milligrams (mg) daily of an unknown benzodiazepine though documentation indicates that the patient used only one to three times in the last 30 days. The patient used alcohol also one to three times in the prior 30 days. The patient had a history of a rehabilitation admission. The patient had been on methadone maintenance prior to admission. Inpatient detoxification services level of care is under review.

The health plan's determination is upheld. The Inpatient Detoxification Services is not medically necessary for this patient.There had been no changes that necessitated a higher level of care. The withdrawal symptoms did not continue to require a 24 hour medical oversight in a hospital setting due to serious and life-threatening complications. The withdrawal did not continue to require medical supervision, stabilization, and regular vital sign monitoring.
The clinical documentation does not establish that the patient needed inpatient care for the dates in question. The patient was not having severe withdrawal symptoms by this time. It appears the patient may have been kept waiting for an available bed in a lower level of care.