Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient who was admitted as an inpatient to the hospital for detoxification treatment from alcohol and benzodiazepines. He presented with withdrawal symptoms including muscle cramps, chills, runny nose, yawning, sleeping problems, elevated heart rate, and elevated blood pressure. He reported a history of withdrawal seizure. He reportedly was drinking very large amounts of alcohol daily and ingesting multiple sticks of benzodiazepines weekly. He also had multiple past inpatient detoxification treatments with subsequent relapses. He reported that he could not detoxify on his own. He also had comorbid bipolar disorder and had multiple past psychiatric hospitalizations. He was admitted and was treated with a Librium taper. He was stabilized and was discharged on day 7 of admission with referral to inpatient substance/alcohol rehabilitation treatment. 
  
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 current or 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. Also, the 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 a history of past complicated severe withdrawal as he had a past withdrawal seizure and required 24-hour medical detoxification treatment in the hospital as a result. He was at risk of even more severe and life-threatening withdrawal including delirium tremens. He also had active withdrawal symptoms and was drinking very large amounts of alcohol daily. He was at risk of overdose from his use of a large amount of alcohol with benzodiazepines. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use very large amounts of alcohol daily, required and received detoxification medication, Librium, to modify his withdrawal and prevent another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens from occurring. Also, his history was significant for multiple past inpatient detoxification treatments with subsequent relapses and he reportedly could not detoxify on his own. He also had comorbid bipolar disorder and multiple psychiatric hospitalizations in the past that put him at risk for life-threatening overdose or withdrawal. 

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 hospital admission should be overturned. The medical necessity is substantiated.