Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Stay. 

The insurer denied coverage for inpatient stay. 

The denial is overturned. 

The patient was admitted due to alcohol withdrawal symptoms. She reportedly had tremors, elevated heart rate of 107, high blood pressure, agitation, sleeping problems, concentration problems, and was falling and hitting her head due to alcohol use. She reportedly had diagnoses of major depressive disorder and generalized anxiety disorder in addition to alcohol use disorder. She reportedly increased drinking alcohol after a friend's death. She reportedly was drinking 3 drinks daily. She also reportedly was abusing cocaine. Her longest reported abstinence was a few weeks. She reportedly was in psychiatric treatment and taking Lexapro, Olanzapine, Gabapentin, Xanax, and Lamictal. She reportedly was living with her husband and children and had reported discord with her husband. She was started on a Clinical Institute Withdrawal Alcohol (CIWA) protocol with Librium, given a banana bag and then thiamine and folate. She was discharged but declined the recommendation for inpatient alcohol/substance 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 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the US 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 active alcohol withdrawal symptoms including tremors, elevated heart rate of 107, high blood pressure, agitation, sleeping problems, concentration problems, and was falling and hitting her head due to alcohol use. She reportedly increased her alcohol use and was drinking daily which put her at risk for more severe, complicated, and life-threatening withdrawal. 

The medical records provided enough specific evidence to support that the patient required 24-hour hospital treatment. 

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

The insurer's denial of coverage for the inpatient stay is overturned. Medical necessity is substantiated.