Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned. 

This is a male patient who was admitted to inpatient hospital due to seizures associated with alcohol withdrawal. The patient had two episodes of seizures and had alcohol withdrawal symptoms including a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 9. The patient reportedly was drinking 2 pints of vodka per day. The patient had a history of alcohol withdrawal seizures and had inpatient detoxification treatment in the past. The patient also had an immunocompromising medical condition. The patient was given diazepam and then Librium, and was put on a Librium taper for detoxification treatment and also given intravenous (IV) thiamine and IV fluids. The patient was discharged to an inpatient detoxification/rehabilitation facility for further detoxification.

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. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. In this case, this patient had comorbid medical conditions complicating the management of his alcohol withdrawal. The patient's past history of alcohol withdrawal seizures also put him at risk for life threatening withdrawal symptoms that warranted inpatient level of care and detoxification treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment since his clinical presentation could not have been safely and effectively treated for detoxification in a less restrictive setting. The patient continued to use large amounts of alcohol daily including 2 pints per day of vodka, required and received detoxification medication, Librium, and also diazepam to modify his withdrawal symptoms from alcohol and to prevent another withdrawal seizure. The patient's risk of delirium tremens can occur 3-4 days after alcohol use so this patient was considered at high risk for this as he had active withdrawal symptoms even after the 2 withdrawal seizures and required inpatient hospital detoxification treatment. Based on the review of the medical record and literature, this patient required inpatient hospital admission for his seizure and alcohol detoxification, and continued to require inpatient hospital detoxification/rehabilitation upon initial workup and stabilization. 

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 hospital admission should be overturned. The medical necessity is substantiated.