Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male who was admitted to this hospital for detoxification from alcohol and heroin. He was subsequently admitted to telemetry due to chest pain and dizziness for rule out of coronary artery syndrome and for continued detoxification, and was followed by the psychiatry consultant. He was put on a Librium and Methadone protocol and also was given Ativan when necessary (PRN) until a specified date. He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) as high as 14 on day three. He was drinking 3-4 pints of vodka per day and using 8-12 bags of heroin daily, and had a positive toxicology for opiates. He reportedly became agitated, aggressive, loud, psychotic including auditory hallucinations and responding to internal stimuli, confusion, had disruptive behavior, and noncompliance and he continued to require extra Ativan due to being treated for impending DT's (delirium tremens) and had agitation and hallucinations. He was homeless and unemployed. He had comorbid depression and anxiety. He had a significant medical history for hypertension, diabetes, gastroesophageal reflux disease (GERD), and neuropathy. He was on 1:1 observation.  He was discharged when stable with referrals to inpatient rehabilitation.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatments. This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the chart notes provided enough specific evidence to support that he was in need of hospital treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 reports that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens 3-4 days after cessation of use. It also states that patients with comorbid medical conditions complicating that management of withdrawal are candidates for inpatient hospital treatment.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he had impending DT's with confusion, severe agitation, hallucinations, and was considered a danger to self and others in need of 24 hour hospital treatment and was on continuous 1:1 observation.  Also, he continued to use large amounts of alcohol up to 3-4 pints per day and large amounts of heroin up to 12 bags per day and was at risk of overdose and life threatening withdrawal. He also was homeless and lacked supports and could not safely be treated for detoxification in an outpatient setting. 

The patient continued to require behavioral and detoxification treatment and was considered a high risk of danger to self and a risk of danger to others still. He required 24 hour hospital treatment for detoxification treatment and behavioral treatment due to alcohol withdrawal symptoms. He reportedly was discharged with referrals to rehabilitation treatment. 

As a result, the determination is to reverse the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably, with sound clinical judgment, 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 reversed.