Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse

Treatment:  Inpatient substance abuse admission

The insurer denied coverage for inpatient substance abuse admission.  The denial reversed.

This patient is a male who was admitted to this inpatient substance detoxification treatment in this hospital due to alcohol detoxification.  He had withdrawal symptoms including tremors, irritable mood, nausea, and anxiety and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 11.  He was drinking 6-8 sixteen ounce beers per day and was using multiple dollars of intranasal cocaine.  The patient was also using benzodiazepines.  He had a diagnosis of Bipolar Disorder.  He lacked coping skills for sobriety and also lacked the ability to identify relapse triggers.  He had multiple prior inpatient detoxification treatments and outpatient substance treatments.  He had a Librium protocol and took Librium for modification of withdrawal and was discharged.

The insurer denied coverage for inpatient substance detoxification treatment in this hospital.  This reviewer disagrees with the decision to deny coverage for inpatient hospital detoxification treatment, as the chart notes provided enough specific evidence to support that he required 24-hour hospital treatment for detoxification.  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, 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 had current withdrawal symptoms and was at risk for severe, complicated, and life-threatening withdrawal symptoms; therefore, he required 24-hour inpatient hospital detoxification treatment.

According to LOCADTR, the patient did require 24-hour hospital treatment, as he could not safely and effectively be treated in outpatient detoxification settings. This was evidenced by the fact that he had past inpatient detoxification treatments and still could not stop use due to lacking coping skills for sobriety and also lacking the ability to identify relapse triggers.  Also, he required and received detoxification medication, Librium, to prevent life-threatening withdrawal.  This was needed in a hospital setting due to the large amount of use and the use of cocaine and benzodiazepines, in addition to the large amount of daily alcohol use. Because of this, inpatient residential detoxification treatment was not considered safe enough treatment due to his high risk for life-threatening withdrawals.  He needed 24-hour inpatient detoxification hospital treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting. He required medical hospital detoxification treatment as he was considered a high risk for life-threatening withdrawals and had active withdrawal symptoms. Also, he was taking Librium for detoxification.

As a result, reverse the previous decision and approve coverage for continued inpatient substance hospital detoxification.  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 substance abuse admission is substantiated.  The insurer's denial is reversed.