Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizoaffective Disorder; Alcohol Use Disorder

Treatment: Continued stay in a behavioral health hospital

The insurer denied coverage for continued stay in a behavioral health hospital. The denial is modified. 

This patient is a male who was admitted to this inpatient hospital treatment due to severe psychiatric symptoms including command auditory hallucinations to kill himself, suicidal thoughts, disorganized thinking, disruptive behavior, noncompliance with medications, depressed mood, and alcohol withdrawal symptoms including moderate tremors, anxiety, and an irritable mood. He had a past alcohol withdrawal seizure. He was uncooperative, had poor hygiene, and limited insight and judgment. He had a blood alcohol level (BAL) of 399 initially. He was drinking 2 pints of liquor and 12 ounces of beer daily. He had diagnoses of Schizoaffective Disorder, as well as Alcohol Use Disorder. He had multiple past psychiatric hospitalizations and past inpatient detoxification treatments. He was put on a Librium taper and it was reported that he took Librium. He also took Abilify and Trazodone. He was discharged. The insurer denied coverage for continued inpatient behavioral health treatment.

This reviewer disagrees with the decision to deny coverage for continued inpatient behavioral health treatment in this hospital for specified dates but agrees with the decision to deny inpatient behavioral health treatment in this hospital for other specified dates. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. Initially, this patient had reports of command auditory hallucinations to kill himself, suicidal thoughts, disorganized thinking, disruptive behavior, noncompliance with medications, depressed and irritable mood, and limited insight and judgment. He had poor hygiene and was uncooperative. Notes on a specific date reported that he still required and received detoxification medication, Librium 10 mg, twice to modify withdrawal and prevent complicated and life-threatening withdrawal. 

The 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 using large amounts of alcohol daily and had withdrawal symptoms. Additionally, he had a prior complicated alcohol withdrawal including a prior withdrawal seizure and was at risk for complicated and life-threatening withdrawal. He had received detoxification medication until a specific date. 

According to the LOCADTR, he did require 24-hour inpatient detoxification treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. This was due to the fact that he continued to use large amounts of alcohol and needed detoxification medication with multiple doses of Librium for detoxification. The risk of life-threatening and complicated withdrawal such as delirium tremens can occur days after alcohol use; therefore, he required this time from a specified range as he was receiving detoxification medication at that time, but not thereafter.

The insurer acted reasonably and with sound medical judgment and in the best interests of the patient from a specified range, but not from another specified date range.

Based on the above, the insurer's denial for the continued stay in a behavioral health hospital is modified.