Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse. 

Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 

The denial was overturned.   

This is a male patient who was admitted to the hospital for inpatient detoxification treatment. He had a history of Schizoaffective Disorder and multiple past inpatient substance detoxification treatment as well as past inpatient substance rehabilitation treatment. He reported drinking 1 pint of brandy per day, and using 2 grams of crack and cocaine per day. He reportedly had lost his job, wife, and apartment and was homeless. He had withdrawal symptoms and was started on Librium with taper dosage. He was discharged with instructions to follow up with his primary care provider. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence, patients who relapse frequently, 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. In this case this patient had been drinking large amounts of alcohol daily including 1 pint of brandy per day putting him at significant risk of more severe, complicated or life threatening withdrawal and he had active withdrawal symptoms reported on admission. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in less restrictive levels of care as he was considered a high risk for more complicated and life threatening withdrawal and he had current alcohol withdrawal and required and received detoxification medication as he received Librium each day then for detoxification treatment. He was considered a risk medically due to his amount of daily drinking so he required 24 hour inpatient hospital detoxification treatment. He continued to drink 1 pint of brandy per day and had a reported a long history of alcohol use, smoking 2 grams of crack daily and inhaling 2 grams of cocaine per day despite multiple past inpatient detoxification and rehabilitation treatments. It was reported that he had over 20 inpatient detoxification treatments. The risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use so he required the time in this inpatient hospital detoxification treatment. He also had comorbid psychiatric conditions including Schizoaffective Disorder and comorbid medical issues including diabetes and hypertension which further complicated the treatment of withdrawal. He also lacked supports and coping skills and was homeless and unemployed. 

It did not appear that the health care plan acted reasonably or in the best interests of the patient. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.