Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use and Shortness of breath. 

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a male patient who was admitted to the hospital due to shortness of breath, severe pain, and it was reported that he was retching, was an active cocaine user, and also had alcohol use.  The patient had multiple medical issues including poorly controlled immunocompromising illness, anemia secondary to alcohol induced bone marrow suppression, severe malnutrition including being cachectic, alcohol gastritis, and a history of multiple hospitalizations for falls.  It was reported that the patient had a Medical Intensive Care Unit (MICU) stay for severe cellulitis which required surgical intervention.  The patient reportedly had a recent substance rehabilitation treatment and left against medical advice (AMA).  It was reported that the patient's wife brought the patient to this hospital.  The patient was put on an Ativan protocol for detoxification, intravenous (IV) thiamine, seizure precautions, and antacids.  However, the patient left against medical advice (AMA) on day 2 of admission.

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 are in need of 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.  

In this case, this patient could not safely be treated in a less restrictive detoxification treatment level of care other than an inpatient hospital treatment as he was at risk for severe, complicated, and life threatening withdrawal due to alcohol use, and he reportedly had comorbid medical issues complicating the management of withdrawal as he had a significant medical history of poorly controlled immunocompromising illness, anemia secondary to alcohol induced bone marrow suppression, severe malnutrition including being cachectic, alcohol gastritis, and had a history of multiple hospitalizations for falls, as well as a past medical intensive care unit (MICU) stay for severe cellulitis which required surgical intervention.  The patient reportedly presented with shortness of breath, retching, and severe pain.  The patient was considered a medical risk due to his multiple medical issues and was considered in need of 24-hour hospital treatment for detoxification as he was put on an Ativan protocol and seizure precautions.  The patient relapsed shortly after leaving inpatient substance rehabilitation against medical advice (AMA).  The patient could not maintain abstinence outside of a 24-hour setting for detoxification treatment.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification protocol treatment.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient admission should be overturned.  The medical necessity is substantiated.