Diagnosis: Substance abuse
Treatment: Inpatient detoxification treatment
The Inpatient detoxification treatment was medically necessary for this patient.

The requested benefit of Inpatient detoxification treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol together with benzodiazepines that did warrant inpatient level detoxification and withdrawal management and monitoring. The patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms, as noted in the clinical summary. There was a history or frequent blackouts and falls with injury and severe symptoms of withdrawal in the past. The patient displayed limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient stay for detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments and co-occurring psychiatric disorder do reflect the seriousness of the substance use disorder and co-occurring disorder with persistent anxiety that served to trigger the patient's substance use. Again, the clinical features and treatment dimensions in this case do warrant and support the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and consistent with New York State instruction for medical necessity reviews including the appropriate application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines that requires that the patient default to the higher level of care in this case scenario-referenced below.

The requested benefit of Inpatient detoxification treatment is clinically appropriate, medically necessary and warranted, and should, therefore, be covered in this case scenario. The Substance abuse detoxification and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the Inpatient detoxification treatment should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.