Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient hospital stay

The insurer denied coverage for the inpatient hospital stay.

The denial is overturned.

This is a male patient with a history of alcohol abuse, polysubstance abuse, nicotine dependence, marijuana use, and depression. He presented to the Emergency Room (ER) with complaints of withdrawal symptoms. The patient was seeking detoxification from alcohol, methadone, and crack cocaine. He was homeless and unemployed, and had a past history of incarceration. The patient reportedly had withdrawal symptoms including tremors, diaphoresis, tachycardia, nausea and vomiting, diarrhea, facial flushing, malaise, rhinorrhea, abdominal cramps, muscle cramps, piloerection, sleeping problems, and anxiety. He reported drinking 2 or more pints of vodka per day and up to ten 24 ounce beers per day. He also reported using methadone and cannabis. He was admitted for inpatient detoxification treatment. The patient's urine toxicology was positive for cocaine and benzodiazepines. His treatment included Zoloft and Wellbutrin for anxiety and depression, and he was put on a Librium taper for detoxification treatment. The patient also took Campral, thiamine, and folic acid for his inpatient treatment. The patient was discharged after treatment to an inpatient substance rehabilitation center. 

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. 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 comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. In this case, this patient could not safely be treated in a less restrictive detoxification setting as he reportedly had active withdrawal. He was at high medical risk and high risk for life threatening withdrawal such as delirium tremens. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification protocol treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol, crack/cocaine, Methadone, and cannabis despite past inpatient detoxification. The patient also required detoxification medication protocols to modify his withdrawal symptoms and prevent complications such as delirium tremens. Based on the patient's drinking habit that included large amounts of alcohol, crack/cocaine use, Methadone and cannabis use, this patient was also at risk for overdose and death. As this patient was homeless and unemployed, he lacked support and the ability to be treated at a less restrictive setting. Thus, inpatient hospital for detoxification treatment was medically necessary for this patient. 

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 hospital stay should be overturned.