Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial was overturned.

This is a male patient with a history of hypertension and osteoarthritis. He presented to the hospital for alcohol detoxification. It was reported that the patient had uncontrolled diabetes with elevated glucose level of 421 and Hemoglobin A1C of 12.4 due to noncompliance with medication. The patient reported that he was drinking 5-6 shots of vodka per day and was using $100 worth of cocaine a few times per week. The patient was admitted to the hospital and was placed on Ativan detoxification protocol. He received insulin to control his glucose levels. The patient was treated and was transferred to a substance/alcohol rehabilitation facility. 
 
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. 

In this case, this patient could not have been safely treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to his daily alcohol use, and he reportedly had serious comorbid medical issues complicating the management of withdrawal as his glucose was very high due to his uncontrolled diabetes and noncompliance with medication. The patient was put on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol with Ativan due to his daily large amount of alcohol use. The patient also required intravenous (IV) hydration. The patient also had hypertension, and was reportedly living in a shelter with limited supports. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so the patient required inpatient detoxification protocol treatment. The patient was at risk medically as he had active medical issues including uncontrolled diabetes that required inpatient stabilization especially with his history of noncompliance with medication and chronic alcoholism. 

Based on the review of the medical record and literature, the patient required inpatient detoxification and medical stabilization prior to his transfer to a 24-hour inpatient substance rehabilitation treatment for alcohol rehabilitation. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

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