Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Substance Abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed.

This patient is a male who was admitted for inpatient hospital detoxification treatment.  The patient exhibited withdrawal symptoms from alcohol including nausea, vomiting, cravings and urges, weakness, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 8.  The patient was noted to be dehydrated and had been drinking several pints of vodka per day.  The patient also reported using cannabis a few times per week and cocaine with last use several weeks prior to admission.  The patient's history was significant for multiple past inpatient detoxification and rehabilitation treatments.  The patient lacked coping skills to stop alcohol use.  The patient was treated with Librium for detoxification, as well as intravenous (IV) fluids, IV Pepcid, Reglan, Magnesium, Zofran, Rocephin, and multivitamins. The patient was noted to be unemployed.

 American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case, this patient had reports of drinking large amounts of alcohol for a long time and was considered to be at a high risk for severe, complicated, and life threatening withdrawal as a result and required inpatient hospital detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to large amounts of use alcohol daily, and required Librium detoxification medication to help modify his withdrawal from alcohol on admission. The risk of life-threatening withdrawals, such as delirium tremens can occur 3 to 4 days after alcohol use. Given this patient's chronic use of large volume of alcohol and history of requiring multiple inpatient detoxifications, this patient was at risk for delirium tremens if not monitored and treated within a 24-hour inpatient setting. The patient lacked coping skills for abstinence and was at high risk for relapse. Based on the review of the medical record and the literature, inpatient admission for detoxification was medically necessary to safely treat this patient's alcohol withdrawal symptoms.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be reversed.  The medical necessity is substantiated.