Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Dependence, Cocaine Dependence

Treatment: Medically supervised inpatient detoxification

The insurer denied coverage for medically supervised inpatient detoxification.

The denial is overturned.

This patient was admitted to the inpatient hospital detoxification treatment for a medically supervised inpatient detoxification treatment. He reportedly had withdrawal symptoms including tremors, sweats, agitation, anxiety, elevated heart rate, diffuse discomfort, nasal stuffiness, and had a Clinical Institute Withdrawal Alcohol (CIWA) of 10 and Clinical Opiate Withdrawal Score (COWS) of 6. He reportedly had a positive toxicology for cocaine and benzodiazepines. He reportedly was drinking 1 pint of liquor per day and using 2 mg (milligrams) of Xanax per day, as well as smoking $80 worth of crack per day. He reportedly had hepatitis C and hypertension. He reportedly had comorbid bipolar disorder. He reportedly had a diagnosis of Alcohol Use Disorder. He reportedly had multiple past inpatient detoxification treatments and past inpatient rehabilitation treatment, as well as a past psychiatric hospitalization. He reportedly could not maintain any prolonged period of abstinence. He reportedly was unemployed. He reportedly was put on an Ativan taper for detoxification and started Ativan and received multiple doses including 3 doses, and also still had another does but left against medical advice (AMA).
   
The 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. In this case this patient had been drinking large amounts of alcohol daily including up to 1 pint per day and also was using 2 mg of Xanax per day which put him at risk for severe, complicated, and life-threatening withdrawal so he required 24 hour inpatient hospital detoxification treatment then as he was at risk medically. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use large amounts of alcohol daily despite medical issues and bipolar disorder and he required and needed detoxification medication, Ativan, to modify and treat withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. Also, he reportedly had active withdrawal symptoms including tremors, sweats, agitation, anxiety, elevated heart rate, diffuse discomfort, nasal stuffiness, and had a CIWA of 10 and COWS of 6 so it was unlikely that he would remain abstinent while still having withdrawal symptoms. He reportedly could not maintain any prolonged abstinence despite multiple past inpatient substance detoxification treatments and an inpatient rehabilitation treatment. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this medical inpatient detoxification setting including when he left against medical advice (AMA) despite the recommendation for a 5-day inpatient detoxification treatment in this hospital setting. 

Inpatient substance/alcohol detoxification was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.  

The insurer's denial of coverage for medically supervised inpatient detoxification is overturned. Medical necessity is substantiated.