Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment is inpatient detoxification treatment
 
The insurer denied coverage for inpatient detoxification treatment

The denial is overturned

This male reportedly was admitted to this inpatient hospital for detoxification treatment from alcohol. He reportedly had alcohol withdrawal symptoms including tremors, anxiety, tongue fasciculations, elevated heart rate of 105, elevated blood pressure of 159/94, abdominal cramps, chest pressure and a CIWA (Clinical Institute Withdrawal Assessment) of 8 which increased to 9. He reportedly was drinking large amounts of beer including 18 per day. He reportedly had past inpatient alcohol treatments in 2019 and 2020 and a past outpatient alcohol treatment in 2021 and reportedly relapsed. He reportedly relapsed due to triggers by work and family stressors. He reportedly also had depression and was started on Lexapro. He reportedly had medical issues including hypertension, hyperlipidemia, and transaminitis, as well as abnormal EKG (electrocardiogram) with a left posterior fascicular block. 
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment for detoxification treatment as the medical records provided enough specific evidence to support the need for inpatient hospital treatment then. 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, anxiety, tongue fasciculations, elevated heart rate of 105, elevated blood pressure of 159/94, abdominal cramps, chest pressure and a CIWA of 8 which increased to 9 and had comorbid medical conditions including hypertension, hyperlipidemia, and transaminitis, as well as abnormal EKG with a left posterior fascicular block. 

It was not likely that he could not be effectively and safely treated in a less restrictive setting than this inpatient hospital setting as he was drinking large amounts of alcohol daily and he reportedly relapsed after 2 past inpatient alcohol treatments as well as outpatient alcohol treatment so he needed inpatient detoxification prior to his discharge to inpatient alcohol rehabilitation treatment.  As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment as he was discharged to inpatient alcohol rehabilitation treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

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