Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol/substance Detoxification

Treatment: inpatient substance abuse treatment

The insurer denied coverage for inpatient substance abuse treatment

The denial is overturned

This patient is a male who was admitted for inpatient hospital treatment for alcohol/substance detoxification treatment.  The patient reportedly had alcohol withdrawal symptoms including agitation, sweats, nausea/vomiting, headache, tactile and auditory hallucinations, light sensitivity, elevated heart rate, disorientation to date, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 14.  The patient reportedly was drinking 1 pint of vodka per day and started alcohol use at an early age.  The patient reportedly was using $200 worth of crack/cocaine per day and also using Xanax.  The patient reportedly had a recent inpatient detoxification.  The patient was put on a Librium protocol.  The patient had alcohol withdrawal symptoms again with a CIWA score of 14.  The patient was disruptive on the floor, noncompliant with rules and regulations including not wearing a mask and walking barefoot.  The patient left against medical advice (AMA). 

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 with daily crack/cocaine use and Xanax use putting him at high risk for life threatening withdrawal and also for overdose or worsened medical issues.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour hospital treatment as he could not safely and effectively be treated in a less restrictive detoxification setting as he continued to use large amounts of alcohol daily despite medical issues and he required and needed detoxification medication to modify withdrawal and needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting. It was reported that the patient was put on a Librium protocol for detoxification. The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required the entire time as he had Clinical Institute Withdrawal Assessment of Alcohol (CIWA) scores of 14 on both days and has active symptoms of moderate withdrawal. 

The patient also had comorbid medical issues.  The patient was considered a high medical risk.  The Office of Addiction Services and Supports (OASAS) criteria also for medically managed detoxification includes a CIWA of 12 or more and hallucinations within 24 hours; this patient had both of these criteria as his CIWA score was 14 and he had tactile hallucinations and auditory hallucinations.  The patient continued to use large amounts of alcohol daily and large amounts of crack/cocaine daily as well as Xanax despite a recent inpatient hospitalization.  The patient was considered a high risk patient medically and required 24-hour hospital treatment. 

The coverage for inpatient alcohol/substance detoxification is considered medically necessary for this patient. 

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

Based on the above, the medical necessity for the inpatient alcohol/substance detoxification is substantiated. The insurer's denial should be overturned.