Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: inpatient substance admission 

The insurer denied the inpatient substance admission. The denial was overturned.

This is a male patient with a history of alcohol abuse, cocaine abuse, heroin abuse, benzodiazepine abuse, schizophrenia, depression, liver disease, and prior detoxification who was admitted to the hospital due to alcohol and substance withdrawal, and the need for detoxification treatment. The patient reportedly had withdrawal symptoms and required two detoxification medications including Librium and Suboxone. The patient also reported suicidal ideation, homicidal threats, and had depression. The patient reportedly was drinking 1 pint of vodka per day and he reportedly took 5-6 Klonopin pills the day prior to coming into the hospital. The patient reportedly was homeless and unemployed. The patient was also treated with Seroquel and Effexor. The patient was cleared for discharge to inpatient substance rehabilitation.
  
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 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 due to his large amount of daily alcohol use. The patient also reportedly took a large amount of benzodiazepine including 5-6 Klonopin prior to hospital admission, and also was taking opiates and had a history of cocaine use. The patient was at risk for overdose, as well. The patient's polysubstance use was also complicated by medical issues such liver disease, and psychiatric instability. The patient reportedly had suicidal ideation, homicidal threats, and had depression, and was noncompliant with psychotropic medication. This put this patient at danger to self and others. The patient was noted to be homeless, unemployed, and lacked sober support. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not have been safely and effectively treated in outpatient detoxification settings or a less restrictive setting. The patient's continuous use of large amounts of alcohol and substances despite medical issues and psychiatric issues including suicidal ideation, depression, and homicidal threats and noncompliance to treatment indicated inpatient level of care for detoxification. The patient's need for two detoxification medications to modify his withdrawal symptoms and to prevent life-threatening withdrawal also indicate the severity of this patient's needs that require inpatient level of care. It was reported that the patient had detoxification medication of Librium and Suboxone as well as prn Ativan until his discharge to the inpatient substance rehabilitation treatment. 

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

Based on the above, the medical necessity for continued inpatient substance admission is substantiated.  The insurer's denial should be overturned.