Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Hospital Admission

The insurer denied coverage for hospital admission.

The denial is overturned.

This patient was admitted to inpatient hospital treatment for alcohol and heroin detoxification. He reportedly had withdrawal symptoms including withdrawal seizure, nausea, vomiting, gastrointestinal (GI) upset, tremors, headache, diarrhea, chills, visual disturbances, irritable mood, anxiety, increased heart rate, yawning, runny nose, and photophobia. He reportedly had Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 13 and Clinical Opiate Withdrawal Scale (COWS) of 8. He reportedly was drinking 18-24 beers per day and also drank hand sanitizer and was snorting 20 bags of heroin. He reportedly lacked a sober support system and was homeless and unemployed. He reportedly had a toxicology positive for alcohol and benzodiazepines. He had QTc (interval on echocardiogram) prolongation. He reportedly had multiple past inpatient substance detoxification and rehabilitation treatments, and outpatient treatment. He was given 2 detoxification medications including Ativan and Suboxone and was put on seizure precautions. He was discharged.
  
In this case this patient had reports of an alcohol withdrawal seizure which requires inpatient medical detoxification treatment and also had active withdrawal symptoms including nausea, vomiting, GI upset, tremors, headache, diarrhea, chills, visual disturbances, irritable mood, anxiety, increased heart rate, yawning, runny nose, photophobia, and reportedly had a CIWA of 13 and COWS of 8. He also had prolonged QTc. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily including up to 24 beers per day and also used hand sanitizer as well as large amounts of heroin including snorting up to 20 bags per day. He also required and received 2 detoxification medications including Ativan and Suboxone to modify withdrawal from alcohol and prevent another withdrawal seizure, more severe withdrawal, or complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for severe, complicated, and life-threatening withdrawal. He also continued to use large amounts of alcohol and heroin daily putting himself at medical risk for overdose and life-threatening withdrawal despite multiple past inpatient detoxification and rehabilitation treatments as well as outpatient alcohol/substance treatments. He lacked supports and was homeless and unemployed. He did require 24-hour inpatient medical hospital treatment for alcohol and heroin detoxification and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He was considered a high risk medically and also for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment then. 

Inpatient hospital treatment was medically necessary.  It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.

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