Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse; active withdrawal symptoms
Treatment: Inpatient admission for substance abuse 
The insurer denied coverage for inpatient admission for substance abuse. 
The denial is reversed. 

This patient is a male was admitted to inpatient hospital treatment for detoxification from alcohol and substances. He had active withdrawal symptoms including sweats, nausea, agitation, visual disturbance, anxiety, depression, numbness, and headache, and he had a Clinical Institute Withdrawal Assessment (CIWA) score of 5 that went to 10. He reportedly had a seizure history with the last reported seizure having been a couple of days before admission. He was drinking shots of vodka and several tall boys per day and had a decade long history of alcohol use. He reportedly was homeless and unemployed. He reportedly had a positive toxicology for benzodiazepines and ethylglucuride. He reportedly was started on a Librium protocol. He reportedly was transferred to a substance inpatient rehabilitation treatment.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment for detoxification as this was a high risk patient in need of 24 hour detoxification hospital treatment for several days prior to going to the substance inpatient rehabilitation 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 active withdrawal symptoms with a recent seizure several days prior to admission. His CIWA score increased from 5 to 10 and he required detoxification medications. He also was homeless and lacked supports and could not safely be in detoxification outside of this hospital. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol despite medical issues including seizures, homelessness, lack of finances, family and friend discord, and emotional and health issues, and he required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting. He was at risk for severe, complicated, and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this hospital with several days detoxification prior to attending inpatient substance rehabilitation treatment. It was unlikely that he would remain abstinent while still having withdrawal symptoms also. He reportedly could not stop drinking without a 24 hour setting so he likely also could not have been safely and effectively detoxified in a less restrictive setting other than this 24 hour hospital setting.  As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification. It did not appear that the health care plan acted reasonably or in the best interests of the patient then. 

Based on the above, the medical necessity for the inpatient admission for substance abuse is substantiated.  The insurer's denial is reversed.