Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal.

Treatment: Inpatient rehabilitation.

The insurer denied coverage for inpatient rehabilitation.

The denial is overturned.

 
This adult was admitted to inpatient treatment for alcohol detoxification treatment. He had alcohol withdrawal symptoms including nausea, sweats, elevated heart rate of 102, anxiety, sleeping problems, cravings, and an elevated systolic blood pressure of 131. He had a Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-AR) score of 10. He was homeless and unemployed. He was drinking two 40-ounce beers daily. He reported that when he drinks alcohol, he loses all sense of control. He lacked coping skills and the ability to identify relapse triggers. He had diabetes. He was given Ativan 1.5 mg (milligrams) on admission and put on an Ativan taper protocol for alcohol detoxification treatment. He was discharged to an inpatient rehabilitation treatment for alcohol rehabilitation treatment.

The medical records provided enough specific evidence to support that the patient required inpatient detoxification treatment. 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. Also, the US (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. 

According to the Level of Care for Alcohol and Drug Treatment (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 alcohol daily and he had active withdrawal symptoms and required and received detoxification medication, Lorazepam, to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use. He reportedly took Lorazepam (Ativan) for detoxification treatment. He did require 24-hour medical hospital treatment for alcohol detoxification, and he lacked coping skills and enough sober supports to maintain abstinence and lacked the ability to identify relapse triggers. He was in the hospital one day for detoxification prior to coming to this inpatient facility for detoxification treatment. He was considered in need of inpatient detoxification treatment at this facility. He did not have the ability at the time to maintain abstinence without being in this inpatient detoxification setting. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient detoxification treatment.
Based on the above, the insurer's denial must be overturned. 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 inpatient admission is substantiated.