Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a male patient with a history of alcohol and substance abuse. He reported drinking multiple cans of beer and using crack/cocaine daily. He presented to a substance detoxification treatment facility due to his withdrawal symptoms and the need for detoxification treatment. His toxicology exam tested positive for cocaine and cannabinoids. He was treated with Librium protocol during his treatment. He was medically stabilized and discharged. 

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. According to the National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), these academic institutes state that if the clinical criteria for outpatient therapy are not met, inpatient or residential therapy may be indicated for the patient because this has the advantage of placing the patient in a protected setting where access to substances of abuse is restricted although not necessarily eliminated. They also state that hospital treatment is also indicated for patients who have a very high tolerance for the substance of abuse or who developed seizures, delirium or psychosis during a previous withdrawal; and that other medical indications for inpatient therapy include a history of recent head trauma or cerebrovascular accident, acute abdominal pain, jaundice, liver failure, electrolyte imbalance, pneumonia, sepsis, dehydration, arrhythmias, angina, ischemic heart disease, hypertension, severe respiratory disease and age greater than 65 years. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24 hour treatment as he could not have been safely and effectively treated in outpatient detoxification settings, as he continued to use alcohol daily with a long history of use since an early age with increasing use; and he continued to drink large amounts of alcohol daily and use crack/cocaine and cannabis daily despite past inpatient detoxification treatments and past inpatient substance rehabilitation treatment. The patient had comorbid medical conditions with chest pain when he presented to the Emergency Room (ER). Patient required detoxification medication (Librium) to modify withdrawal symptoms, and needed 24 hour inpatient hospital detoxification treatment due to his risk for worsened, possibly life-threatening withdrawal symptoms. Also, the patient likely would have relapsed again as evidenced by his history of relapsing after past treatments. The risk of life-threatening complication and withdrawals, such as delirium tremens can occur 3-4 days after alcohol use so the patient required the extent of hospital stay for close monitoring and Librium treatment. 

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

The carrier's denial of coverage for the inpatient hospital services for medically supervised inpatient withdrawal and stabilization services is reversed.  The medical necessity is substantiated.