Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol, Cocaine, and Cannabis Use Disorder
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned. 

This is a male patient who was admitted to inpatient substance detoxification treatment for treatment of withdrawal symptoms. He reportedly had tremors, anxiety, irritable mood, and teary eyes. He reportedly was drinking 1 pint per day, smoking crack daily, and using cannabis. He reportedly continued to use alcohol and substances despite a recent inpatient substance detoxification treatment. He had diagnoses of Alcohol, Cocaine, and Cannabis Use Disorder.  He was put on a Librium protocol and required and received Librium. He left Against Medical Advice (AMA) on day 4 of admission.

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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. The United States Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case, this patient had been drinking large amounts of alcohol daily as it was reported that he was drinking 1 pint of alcohol per day and using crack daily which put him at risk medically and also for severe, complicated, and life threatening withdrawal.  

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 in outpatient detoxification settings as he continued to use large amounts of alcohol and crack/cocaine despite a recent past inpatient substance detoxification treatment and he required and took detoxification medication, Librium, to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal. He signed out AMA on day 4 of admission. It was unlikely that he would remain abstinent so he required the time in this treatment setting to stop withdrawals and also to decrease the chance that he would relapse again when not in this 24 hour setting as well as to prevent possible life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, so he required the time in this inpatient substance detoxification setting. 

Inpatient substance/alcohol detoxification was medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

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