Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 62-year-old male who was admitted for detoxification on 1/10/18 with the diagnosis of alcohol use disorder severe dependence. The patient endorsed daily consumption of up to 3/4 bottle of wine for 30 years, whiskey daily for 10 years, and smoking cannabis daily. The patient reported his last use of these substances was on 1/9/18. The patient denied any history of blackouts or seizures, and denied any past psychiatric history. He has a medical history of hyperlipidemia, hypertension, obstructive sleep apnea, and has had an abnormal electrocardiogram, which showed a right bundle branch block. He has alcoholic liver disease with probable cirrhosis. His ammonia level was 117, which decreased to 92 on discharge. The patient lives with his wife, who is also newly sober. He was completed with detoxification on 1/16/18. The patient participated in all of the treatments and group processes available during his admission. He was motivated and cooperative. He did show post-acute withdrawals of tremors, anxiety, restlessness, irritability, some agitation, and headache. His family participated in family week. The 2/11/18 progress notes show that his primary obstacle was his resistance to recovery. The patients mood was irritable, and angry, and he demonstrated mild anxiety. His affect was anxious, and memory and concentration were intact. On 2/12/18, he continued to report insomnia and cravings of 1/10. He was not suicidal or homicidal. The patient was intermittently agitated and angry when changes were made but he was not aggressive towards others. He had ongoing feelings of guilt, remorse, and sadness. On 2/14/18, he was reported to show the same post-acute withdrawal symptoms. The patients medications included lansoprazole, vitamins, lactulose, trazodone, fluticasone, Azor, and Livalo. The patient has requested reimbursement for the psychiatric inpatient services provided from 2/12/18 through 2/14/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The patient was experiencing mild to moderate post-acute withdrawal symptoms. He was not a danger to himself or others. He was not aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically stable to the extent that he did not require the monitoring and supervision of a 24-hour facility to render the remainder of his care. He was psychiatrically stable. In addition, his medication management could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and appeared to be working the program. He was cooperative and participating in his treatment plan. No new problems had arisen. Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting, and he could have been stepped down to an ambulatory level of care such as intensive outpatient program (IOP). His family was supportive and it is noted that his wife was newly sober herself. However, this fact is not a reason for the patient to remain in residential care. Relapse risk is inherent among this patient population. All told, the psychiatric inpatient services provided from 2/12/18 through 2/14/18 were not medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.