Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient detoxification admission
The insurer denied the inpatient detoxification admission.
The denial was overturned.

This is a male patient who was admitted to inpatient detoxification treatment in this hospital due to alcohol and crack/cocaine detoxification. He had withdrawal symptoms that included sweating, tremors, nausea, agitation, anxiety, sleeping problems, headache, lightheadedness, and he had an elevated blood pressure of 150/70.  He had multiple prior inpatient substance/alcohol detoxification treatments with the most recent one in late 2019. Additionally, he had a few prior inpatient substance rehabilitation treatments including a recent one in late 2019.  He was homeless and lacked sober supports.  He was put on a Librium detoxification protocol and required and received Librium and clonidine. The plan was for the patient to go to inpatient rehabilitation treatment after inpatient detoxification treatment, but he declined and was discharged.

They stated that he did not have medical or mental health issues requiring 24-hour inpatient treatment and was not an imminent danger to self or others. They recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for inpatient detoxification hospital treatment as the chart notes provided enough specific evidence to support that he required this level of care.  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 using large amounts of alcohol daily and had alcohol withdrawal symptoms on admission including sweating, tremors, nausea, agitation, anxiety, sleeping problems, headache, lightheadedness, and he had an elevated blood pressure of 150/70.  In addition, he was also using crack/cocaine. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. This was evidenced by his continued use of large amounts of alcohol, as well as crack/cocaine. He needed detoxification medication and was on a Librium detoxification protocol. He required and received Librium from for detoxification and was at risk for severe, complicated, and life-threatening withdrawal.  Also, he continued to use alcohol and crack/cocaine despite multiple past inpatient substance/alcohol detoxification treatments with the most recent one in 2019, in addition to a few prior inpatient substance rehabilitation treatments including a recent one in 2019.  He continued to drink large amounts of alcohol daily and used crack/cocaine. He lacked the coping skills to stop alcohol and substance use. He was homeless and lacked sober supports and needed 24-hour hospital detoxification.  Also, he needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including possible life-threatening withdrawal such as delirium tremens.  

The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient.

The carrier's denial of coverage for the inpatient detoxification admission is overturned.  The medical necessity is substantiated.