Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a male admitted to this inpatient hospital due to acute distress with new onset chest pain. He was diagnosed with bilateral pulmonary embolism and concern for new infarct. He also had hypertension, increased heart rate of 114, and was drinking 3-4 doses of alcohol per day for many years and had mild withdrawal symptoms. The patient was put on a Clinical Institute Withdrawal Assessment Alcohol (CIWA) protocol with Librium 25 mg (milligrams) every 8 hours and Ativan 2 mg every 6 hours as needed and was given intravenous (IV) morphine, IV heparin, supplemental oxygen, and aspirin. He was 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. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens need 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. 

The US (United States) 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. 

In this case this patient had several comorbid medical conditions including a pulmonary embolism complicating the management of withdrawal which required 24-hour hospital treatment. He was considered at risk of worsened withdrawal also due to his daily alcohol use and current withdrawal and he was put on a CIWA protocol with Librium. The risk of delirium tremens can occur 3-4 days after alcohol use and the patient was drinking alcohol daily with a 50-year history of use and had significant medical issues including bilateral pulmonary embolism which complicated the management of withdrawal and put him at risk medically. He had hypertension, elevated heart rate of 114, fell after drinking alcohol and was considered in acute distress with new onset chest pain. He was considered a high medical risk and in need of 24-hour hospital treatment including CIWA protocol and detoxification management. It was considered unsafe for him to be treated in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his medical issues and alcohol treatment issues needed which required hospital treatment. 

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.