Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use disorder

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.    
This is a female patient with a history of suicidal ideations. She presented to the hospital with alcohol withdrawal symptoms that included tremors, nausea and vomiting. She had a Clinical Institute Withdrawal Assessment (CIWA) of 20. She reported drinking a liter of vodka per day. It was reported that she had scattered bruises and abrasions from a previous motor vehicle that involved a driving while intoxicated and had been mandated for treatment. Laboratory work up was performed which revealed hemoglobin (Hgb) of 9.6 and hematocrit (Hct) of 29.3, platelets of 106, aspartate aminotransferase (AST) of 102 and alanine aminotransferase (ALT) of 73. She received tapering doses of Ativan 2 mg protocol intramuscular while continuing to evaluate her CIWA. Despite the medical interventions the patient left against medical advice (AMA) the next day.  
This reviewer disagrees with the decision to deny coverage for inpatient detoxification hospital treatment as the chart notes provided enough specific evidence to support that she require this level of care. 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 using large amount of alcohol daily and had significant alcohol withdrawal including a CIWA of 20 and was at risk of complicated and life threatening withdrawal and she required Ativan IM multiple times for detoxification.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol, needed detoxification medication as she had multiple doses of IM Ativan for detoxification and continued to have withdrawal symptoms. She continued to drink large amounts of alcohol daily despite negative consequences from alcohol including a DWI and motor vehicle accident. She lacked the coping skills to stop alcohol use and needed 24 hour hospital detoxification as she was considered a high risk medically. She needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens. She left AMA the day after presentation despite having withdrawal symptoms including tremors, nausea and vomiting earlier that day. This was a high risk patient who continued to have withdrawal symptoms even on the day she left AMA and was considered a high risk medically for severe, complicated, and life threatening withdrawal.   

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.

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