Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This male reportedly was admitted to this inpatient hospital for detoxification treatment. He reportedly had withdrawal symptoms and was drinking 4 pints of liquor per day and taking 3-4 mg (milligrams) of Lorazepam per day. He also reportedly was smoking $25 per day of cannabis and using $30 per week of cocaine. He reportedly had diagnoses of Alcohol and Benzodiazepine Use Disorder. He reportedly had multiple past inpatient substance detoxification and rehabilitation treatments with the most recent inpatient substance detoxification treatment. He reportedly had medical issues including hypertension, hepatitis C, and elevated creatinine. He reportedly had a past psychiatric history as well. He reportedly was divorced and unemployed. He reported his job as a stressor and trigger. He reportedly was put on a Diazepam taper of 10 mg 4 time per day for day 1, 10 mg 3 times per day for day 2, 10 mg twice per day for day 3, and 5 mg twice per day for day 4. He reportedly was discharged with a referral to outpatient substance/alcohol treatment centers.

The insurer denied coverage for inpatient hospital detoxification treatment as not medically necessary treatment. They stated that he did not require 24-hour inpatient detoxification treatment, and they recommended a less restrictive level of care.

The medical records provided enough specific evidence to support the coverage for inpatient hospital detoxification treatment. He required this level of care. The APA (American Psychiatric Association) 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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal. He also was at risk for overdose. 

According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral), he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of alcohol, benzodiazepines, cocaine, and cannabis despite multiple past inpatient alcohol substance detoxification treatments including a recent inpatient substance detoxification treatment as he could not maintain abstinence. He was considered a high risk medically and in need of hospital treatment for detoxification from alcohol, benzodiazepine cocaine, and cannabis and was on a detoxification protocol. 

As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment for detoxification.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.