Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Use.
Treatment:  Inpatient admission.

The insurer denied coverage for the inpatient admission.  The denial is overturned. 

This is a male patient who was admitted for inpatient substance detoxification. The patient reportedly had withdrawal symptoms including tremors, anxiety, sleeping problems, and had a systolic blood pressure of 138.  The patient reported drinking alcohol daily, smoking crack/cocaine daily, and using 2 bags per day 1-2 times per week of marijuana/hashish.  The patient's history was significant for multiple past inpatient substance detoxification treatments.  In this case, the patient was admitted for inpatient substance detoxification and was put on a Librium protocol and received Librium.  He was discharged to a substance inpatient rehabilitation 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 United States 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 could not safely be treated in a less restrictive setting than an inpatient medical hospital detoxification treatment, as he reportedly was at risk for severe, complicated, and life threatening withdrawal if not in this setting.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 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 almost daily, and cannabis/hashish despite multiple past inpatient substance detoxification and inpatient substance rehabilitation treatments including past inpatient substance detoxification treatments.  Also, the patient required and received detoxification medication, Librium protocol to modify his withdrawal, and he had active reported withdrawal symptoms on admission including tremors, anxiety, sleeping problems, and had a systolic blood pressure of 138.  The patient needed 24-hour treatment then, as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including more severe, complicated, and even possible life threatening withdrawal such as delirium tremens.  The risk of delirium tremens can occur 3-4 days after alcohol use, so this patient was considered at risk for this.  The patient also was considered at risk medically, due to his large use of crack/cocaine with alcohol use.  It would have been unsafe to treat this patient at a less restrictive level of care. 

The inpatient admission was medically necessary for this patient.  The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be overturned.  The medical necessity is substantiated.