Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is overturned.

This is a male patient who was admitted as an inpatient to the hospital due to pre-syncope, dizziness, weakness, nausea, diarrhea, diaphoresis, and he had reportedly been using cocaine, cannabis, and drinking alcohol. The patient reportedly had an abnormal electrocardiogram (EKG). The patient had elevated liver function tests and low potassium level. The patient had a positive toxicology for cocaine and tetrahydrocannabinols (THC). The patient was put on a Librium detoxification taper and protocol, and was treated with intravenous (IV) banana bag and potassium chloride supplementation. The patient was also on telemetry monitoring. The patient was treated and was discharged on day 4 of admission.

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.  

In this case, this patient could not safely be treated in a less restrictive setting other than a hospital setting for detoxification treatment and medical issues as he required hospital treatment for detoxification due to his comorbid medical issues. The patient reported symptoms of pre-syncope, dizziness, weakness, nausea, diarrhea, diaphoresis, and he had reportedly been using cocaine, cannabis, and drinking alcohol. The patient reportedly had an abnormal EKG, and also had transaminitis and hypokalemia. The patient's toxicology was positive for cocaine and THC. The risk of myocardial infarction with cocaine use in this patient with medical issues is high enough to warrant an inpatient level of care and monitoring. Also, this patient's medical conditions complicated the management of withdrawal and detoxification. The patient had reports of alcohol use, cocaine, and cannabis use and he was at risk for severe, complicated, and life-threatening withdrawal as well as worsening medical issues.  

As per literature review, 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. The patient was at risk medically as he had active medical issues including cardiac and gastrointestinal issues requiring cardiology and gastroenterology treatments. The patient was not considered safe for detoxification Librium protocol taper treatment in a less restrictive level of care due to his medical issues and further risks of potentially life-threatening withdrawal. Thus, the inpatient admission 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 admission should be overturned. The medical necessity is substantiated.