Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification
Treatment: One-day hospital stay
The insurer denied coverage for one-day hospital stay.
The denial is overturned. 

This patent was admitted to this inpatient hospital for alcohol detoxification. She reportedly had active withdrawal symptoms including nausea, tremulousness, sweats, and had a CIWA (Clinical Institute Withdrawal Assessment for Alcohol) as high as 10. She reportedly was put on a Librium A CIWA protocol and had 2 doses of Librium 50 mg (milligrams) and one dose of Librium 25 mg for detoxification. She reportedly had been drinking 1 liter of vodka per day. She reportedly had multiple inpatient detoxification treatments and also a 4-month inpatient alcohol rehabilitation treatment and still could not maintain abstinence. She had a heart rate of 45. She reportedly had depressed mood and suicidal ideation as well and had a past psychiatric hospitalization. She reportedly had diagnoses of Major Depressive Disorder in addition to Alcohol Dependence with withdrawal. She reportedly lived alone. She reportedly was seen by the psychiatric consultant who ordered Sertraline in addition to Mirtazepine and also recommended inpatient voluntary psychiatric hospitalization, but the patient refused. She also took Disulfiram and Naltrexone. She reportedly was discharged.
   
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with 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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol daily, required and received detoxification medication, Librium, including 2 doses of 50 mg and 1 dose of 25 mg, to modify withdrawal from alcohol and prevent more complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at high risk for this. She reportedly was being monitored in the telemetry unit. She also continued to use large amounts of alcohol despite multiple past inpatient detoxification treatments and also a 4-month inpatient alcohol rehabilitation treatment. She also took Disulfiram and Naltrexone due to her alcohol use problem. She also lacked supports and lived alone. She also had comorbid psychiatric symptoms including depressed mood and suicidal ideation with a diagnosis of major depressive disorder and the psychiatric consultant recommended voluntary psychiatric hospital treatment to which she declined.  She was considered at high risk for more severe, complicated, and life-threatening withdrawal so she required this inpatient medical hospital detoxification treatment then. 

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

The insurer's denial of coverage for the one-day hospital stay is overturned. Medical necessity is substantiated.