Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal seeking alcohol detoxification

Treatment: Medically Supervised Inpatient and Stabilization level of care

The insurer has denied Medically Supervised Inpatient and Stabilization level of care.  The denial was reversed.

This is a male patient admitted to this medically supervised inpatient and stabilization hospital treatment due to alcohol withdrawal and the need for alcohol detoxification treatment. He had active withdrawal symptoms including tremors, sweats, nausea, agitation, and anxiety and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 16. He had medical problems including an immune disorder, past pulmonary embolism, and asthma. He had a reported history of drinking large amounts of alcohol and using cocaine daily. He had past reported inpatient substance detoxification treatments in the form of six past treatments, including one four months prior to this admission. He also was homeless. He had a history of depression. He had Librium and Ativan for detoxification treatment. He was discharged.

The insurer denied coverage for medically supervised inpatient and stabilization hospital treatment as not medically necessary, stating that there were no medical or mental health conditions requiring 24-hour hospital care, and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for the medically supervised inpatient and stabilization hospital treatment as the chart notes provided enough specific evidence to support that he required 24-hour hospital 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. 

In this case, this patient had been drinking large amounts of alcohol daily and using large amounts of cocaine daily and was at risk for severe, complicated, and life-threatening withdrawal as well as overdose. Additionally, he had medical conditions complicating the management of withdrawal and had active withdrawal symptoms including tremors, sweats, nausea, agitation, and anxiety with a CIWA score of 16.  According to the Level of Care of 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. This was evidenced by the fact that he continued to use large amounts of alcohol and cocaine despite medical issues and depression, and he required Librium and Ativan detoxification medications to modify withdrawal. He required 24- hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting including severe, complicated, and life-threatening withdrawal symptoms. He also was homeless and lacked support.

As a result, reverse the previous decision and approve coverage for the medically supervised inpatient and stabilization hospital treatment. The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient.  

Based on the above, the medical necessity for the inpatient hospital services at the Medically Supervised Inpatient and Stabilization level of care is substantiated.  The insurer's denial is reversed.