Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Schizophrenia; substance and alcohol use disorders.
Treatment:  5 days/units of Inpatient Substance Abuse.

The insurer denied coverage for 5 days/units of Inpatient Substance Abuse.  The denial is overturned.

This patient is a male, who was admitted to this inpatient detoxification treatment in this hospital.  He had withdrawal symptoms including tremors, anxiety, and headache and had tremors when not drinking. He was drinking 4 pints of vodka and a 6 pack of beer daily and smoking cocaine.  He had multiple past inpatient detoxification treatments.  He lived alone and was unemployed.  He had psychiatric diagnoses of Schizophrenia in addition to his substance and alcohol use disorders.  He also reportedly had multiple medical issues including COPD, GERD, hypertension, back pain, and arthritis.  He was put on a Librium protocol.  He also reportedly took Seroquel and Depakote.  He was discharged.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be 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 large amount of daily alcohol use, including drinking 4 pints of vodka and a 6 pack of beer , so he was considered a high risk medically and in need of 24-hour hospital detoxification treatment.  He also reportedly had comorbid medical and psychiatric issues.

Also, according to the LOCADTR, he did require 24-hour treatment, as he could not safely and effectively be treated for detoxification in a less restrictive setting, as he continued to use large amounts of alcohol despite multiple past inpatient detoxification treatments.  He required detoxification medication, Librium, to modify withdrawal from alcohol and prevent more serious complicated and life threatening withdrawal.  He required 24-hour inpatient hospital detoxification treatment then, as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then, including possible life threatening withdrawal such as delirium tremens.  The risk of delirium tremens can occur 4 days after alcohol use, so he was considered at risk for this.  It was reported that the Librium detoxification treatment was completed, and he was discharged with referral. 

Inpatient detoxification treatment in this hospital was medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.

Based on the above, the medical necessity for the 5 days/units of Inpatient Substance Abuse is substantiated.  The insurer's denial is overturned.