The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.

The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.

The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient substance abuse treatment is not medically necessary for this patient.

The proposed treatment and other inpatient 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 alcohol use disorder did not require 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 with alcohol. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.