Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This male patient has a history of substance use disorder. He was admitted to inpatient hospital treatment for detoxification as he had withdrawal symptoms including tremors, elevated heart rate, nausea, headache, irritable mood, anxiety, photophobia, and had a positive toxicology for benzodiazepines, cocaine, and alcohol. The patient reportedly had multiple past inpatient substance treatments and relapsed after them, including one within a week of this admission. The patient reportedly was using alcohol, crack/cocaine, and benzodiazepines. The patient had comorbid psychiatric issues and medical issues including hypertension, asthma, and eczema. The patient was homeless and unemployed and had past reported legal problems. The patient was put on Librium taper and clonidine as needed (PRN) for detoxification and was also given thiamine and folic acid. The patient was discharged after 4 days to a community residential treatment program for aftercare. 

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. In this case this patient had been using large amounts of alcohol daily and crack/cocaine and had a positive toxicology for benzodiazepines, cocaine, and alcohol. He had alcohol withdrawal symptoms on admission including tremors, elevated heart rate, nausea, headache, irritable mood, photophobia, and anxiety. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient 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 and crack/cocaine, needed detoxification medication as he had a Librium detoxification protocol to modify and prevent more severe, complicated, or life-threatening withdrawal. Also, the patient continued to use large amounts of alcohol and substances despite multiple past inpatient substance/alcohol detoxification treatments with the most recent one within one week of this admission and he had a few past inpatient substance rehabilitation treatments, as well. The patient continued to drink large amounts of alcohol daily and lacked the coping skills to stop alcohol use, and he was homeless, unemployed, had past legal issues, and lacked sober supports. He needed 24-hour hospital detoxification. The patient needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including possible life-threatening withdrawal such as delirium tremens. 

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

Based on the above, the medical necessity for inpatient hospital admission is substantiated. The insurer's denial should be overturned.