Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.


This is a female patient who presented to the emergency department with complaints alcohol withdrawal symptoms that included of shortness of breath, weakness, and lightheadedness, tremors, nausea, increased heart rate, elevated blood pressure of 150/97, and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 12. 
As a result, the patient had increased symptoms of depression and use of alcohol. The patient had a recent inpatient substance detoxification treatment. The patient was treated with Librium taper, Ativan, intravenous fluid bolus, folic acid, Neurontin, potassium chloride, vitamin B1, multivitamin. He attended individual and group therapy.   The patient was discharged home with follow up as an outpatient for substance abuse.

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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  Also, the US 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. 

This patient presented to the hospital with active withdrawal symptoms including tremors, nausea, increased heart rate, elevated blood pressure of 150/97, and a CIWA score of 12.  The patient also had reports of shortness of breath, weakness, and lightheadedness and frequent falls. The patient also had recent history of detoxification for alcohol withdrawal.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as she could not safely and effectively be treated in a less restrictive setting. The patient required and received two detoxification medications, Librium and Ativan prn, to modify her withdrawal symptoms from alcohol. The patient's heavy alcohol use and refractory to recent detoxification treatment indicates that this patient was at risk for worsened withdrawal symptoms, such as delirium tremens that needed inpatient monitoring and treatment. According to hospital notes, the patient required and received Librium and Ativan for one day, tapering Librium as per protocol. Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

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