Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient substance abuse

The insurer denied coverage for inpatient substance abuse.  The denial was reversed.

This patient is a male who was admitted to this inpatient hospital after presenting with chest pain, facial injury, back pain, headache, anxiety, loss of consciousness, and a reported asthma attack after being physically attacked by a group.  He reported that he was punched and that a weapon was used.  He also was treated with a Librium protocol for alcohol detoxification.  He had withdrawal symptoms including nausea, tremors, insomnia, anxiety, fatigue, irritable mood, increased heart rate of 99, and agitation.  He was drinking 1 pint to 1/5 per day of liquor and reported the last drink on the morning of admission.  He had a history of blackouts.  He had multiple past inpatient detoxification treatments and 5 past inpatient rehabilitation treatments.  He had past legal issues.  He lacked sober supports.  He became agitated and was physically and verbally aggressive.  He was administratively discharged.

The insurer denied coverage for inpatient substance detoxification treatment stating that it was not medically necessary.

This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the chart notes provided did support that he required 24-hour hospital detoxification treatment.  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.  In this case, this patient had been drinking large amounts of alcohol daily and had current withdrawal symptoms including nausea, tremors, insomnia, anxiety, fatigue, irritable mood, increased heart rate of 99, and agitation.  

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.  This was evidenced by his continued use of large amounts of alcohol despite multiple past inpatient detoxification treatments and past inpatient rehabilitation treatments.  He continued to drink large amounts of alcohol daily.  He also required detoxification including Librium to modify withdrawal and prevent more severe, complicated, or life-threatening withdrawal.  It was unlikely that he would remain abstinent while still having withdrawal symptoms; therefore, he required the time in this treatment setting.  The risk of complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use.  As such, he required inpatient alcohol detoxification treatment.  Additionally, he had a reported history of Bipolar Disorder and Posttraumatic Stress Disorder (PTSD) after the 911 attacks.

As a result, reverse the previous decision and approve coverage for inpatient substance detoxification.  The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient.  

The carrier's denial of coverage for the inpatient substance abuse is reversed.  The medical necessity is substantiated.