Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital treatment  for alcohol detoxification treatment. The patient reportedly had alcohol withdrawal symptoms including sweats, tremors, tactile disturbances, anxiety, headache, agitation, elevated heart rate of 95, and elevated blood pressure of 184/110 and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 12. The patient reportedly had multiple past inpatient alcohol treatments including past inpatient detoxification and rehabilitation treatments, self-help groups, and outpatient treatment and still could not maintain sustained abstinence. It was reported that the patient's longest reported abstinence was 14 months. The patient reportedly was put on a Valium taper at 10 milligrams (mg) 3 times per day, then twice per day, and then daily. The patient reportedly also took thiamine and folic acid. The patient reportedly also had a past suicide attempt roughly 9 years prior and several past psychiatric hospitalizations and had past reported depression and anxiety. The patient reportedly stated that they had interest in outpatient substance/alcohol rehabilitation treatment. The patient reportedly had a CIWA of 3 and was discharged. 

The American Psychological Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour substance rehabilitation treatment as they lacked the coping skills and sober support network to remain abstinent in a less restrictive level of care as evidenced by the fact that he had could not maintain sustained abstinence despite multiple past inpatient substance detoxification and rehabilitation treatments and outpatient treatments.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient met criteria for inpatient substance rehabilitation treatment as they reportedly were using large amounts of alcohol daily including drinking 10 drinks of vodka daily and had a long history of alcohol use. The patient reportedly had a 30-year alcohol use history and could not stop use despite the numerous inpatient substance/alcohol treatments for detoxification and rehabilitation. The patient reportedly was at risk for more severe, complicated, and life-threatening withdrawal and medical risks due to large amounts of daily alcohol use including more severe, complicated, and life threatening withdrawal. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the individual.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient hospital is substantiated.