Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department with symptoms of alcohol withdrawal and generalized weakness. He was medically screened and was provided initial treatment with the diagnoses of severe alcohol withdrawal complicated by rhabdomyolysis, dehydration, and pancytopenia.  He had a Clinical Institute Withdrawal Assessment (CIWA) scale score of 8 with diaphoresis, nausea and vomiting and diarrhea, tactile hallucinations with sensation of bugs crawling on skin, and anxiety, as well as the generalized weakness. He reported stopping his usual medications including Norvasc, Prozac, Haldol, low-dose Seroquel, Depakote, and trazodone. He had a history of withdrawal seizures with at least two prior admissions for alcohol withdrawal, and had hypertension, as well as poor nutrition.
He was admitted for detoxification, withdrawal management, and substance-related services including intravenous (IV) fluids with monitoring with seizure precautions, and hematology and psychiatric consultations with management as clinically appropriate. 
On the Mental Status Examination, there were no severe symptoms on mental status examination and no safety concerns regarding risk of harm to self or others.
The patient received tapering dosages of Librium and replacement of vitamins with education and counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, and insomnia, as well as intravenous (IV) fluid replacement with seizure precautions. The patient's hospital course progressed without incident. He received psychiatric consultation and was prescribed prn use of Haldol and Benadryl with recommendations for resumption of his psychotropic regimen in order to maintain treatment for the schizoaffective disorder-bipolar type and associated symptoms of anxiety and insomnia. Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which the patient declined. He received case management services and planning for clinically appropriate aftercare with discharge against medical advice when cleared by psychiatry.

At issue is the medical necessity of inpatient hospitalization.

The requested health service and treatment, inpatient hospital admission for detoxification treatment and withdrawal management and monitoring and other medical services for dates of service is medically necessary for this patient.
The patient was using large quantities of alcohol and cocaine on a daily continuous basis together with marijuana that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the complicating general medical findings and co-occurring psychiatric disorder could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. The patient's clinical features that included a history of severe withdrawal including seizures and general medical and psychiatric comorbidities did warrant the intensity, monitoring and duration of inpatient level treatment requested. Thus, the adult inpatient hospital stay and continued detoxification treatment of this patient's substance use disorders and other indicated medical services did necessitate the hospital admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring with inpatient level nursing support.