Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Substance Abuse
 
Treatment: inpatient detoxification treatment 

The insurer denied coverage for inpatient detoxification treatment. The denial is reversed. 

This patient is a male who was admitted to this inpatient detoxification treatment for substance and alcohol detoxification treatment.  He had withdrawal symptoms including tremors, nausea, vomiting, sweats, chills, agitation, body aches, anxiety, uncontrollable cravings, elevated blood pressure of 142/94, flushed skin, headache, lethargy, restless legs, and rhinorrhea. The patient had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 13.  He had a past withdrawal seizure from Xanax one year prior to admission.  He was drinking alcohol daily, including two 24-ounce beers/drinks, using up to 6 mg of Klonopin per day, using cocaine and multiple dollars-worth of cannabis daily, and Oxycontin. He had poor coping skills.  He was in outpatient substance treatment and was still using multiple serious substances. He was put on a detoxification protocol with Valium for a specified numbers time frame. He also took Prozac, Tegretol, and Gabapentin.  He was discharged. This reviewer disagrees with the decision to deny coverage for inpatient detoxification treatment as the chart notes did provide enough specific evidence to support that he required this level of care.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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. They also report that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification.  This patient could not safely be treated in an outpatient or PHP detoxification as he had active withdrawal from multiple substances including benzodiazepines and alcohol. In addition, he had a history of a past withdrawal seizure which is considered complicated withdrawal that requires 24-hour detoxification treatment.  He was using large amounts of multiple serious substances and was at risk for overdose or more severe, complicated, or life-threatening withdrawal. 

Also, despite outpatient substance treatment, legal problems and violence related to substance use, he could not maintain abstinence.  He also required and needed detoxification medication (Valium) to modify withdrawal and needed 24-hour inpatient detoxification treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting. It is reported that delirium tremens can occur within 3-4 days after stopping alcohol use.  This patient was having active withdrawal symptoms on admission that continued throughout the admission. He was at risk for complicated and life-threatening withdrawal symptoms for several days after admission.  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 in outpatient or PHP detoxification settings.

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

The carrier's denial of coverage for the inpatient hospital services at the inpatient detoxification level of care is reversed.  The medical necessity is substantiated.