Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Use Disorder 

Treatment: Inpatient substance abuse treatment for 5 days/units

The insurer is denied coverage for inpatient substance abuse treatment for 5 days/units.

The denial is reversed. 

This was then a male patient who was admitted to inpatient hospital for alcohol detoxification treatment. The patient had withdrawal symptoms including tremors, nausea, sweating, high blood pressure, anxiety, and irritable mood. The patient reported drinking 4-5 pints of liquor per day and had past experiences of blackouts with alcohol use. The patient reported the he had multiple past inpatient detoxification and rehabilitation treatments. The patient was admitted and was treated on a 5 day Librium protocol and taper. The patient completed the Librium taper and was discharged.

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 up to 4-5 pints per day and had a long history of alcohol use with experiences of blackouts in the past. On hospital presentation, the patient had active withdrawal symptoms and was at risk for more severe, complicated, or even life threatening withdrawal symptoms.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24-hour treatment as he could not safely and effectively be treated in a less restrictive setting. The patient's pattern of alcohol use was significant with large amount of daily intake despite having multiple, past inpatient detoxification and rehabilitation treatments. At the time of hospital presentation, the patient had active withdrawal symptoms and was deemed medically necessary to treat with the Librium protocol to modify his withdrawal symptoms.

Notes reported that the patient was started on a Librium protocol. Notes reported that the patient was still taking Librium for detoxification. Notes reported that the patient was still taking Librium for detoxification and had tremors. Notes reported that the patient was still on the Librium protocol and was having a good effect from the detoxification treatment. Notes reported that the patient was still on the Librium treatment for detoxification. The patient was then stable for discharge to rehab.

Based on the review of the medical record, this patient lacked supports and did not have stable housing, lacked coping skills and the ability to identify triggers. The patient required this inpatient treatment setting to treat his withdrawal and also to prevent the chance for relapse and life-threatening complications. The risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use so the patient required the entire time including in this inpatient hospital setting. The patient was appropriately discharged.

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 substance abuse treatment for 5 days/units is substantiated. The insurer's denial should be reversed.