Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse and Suicidal Ideation
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient was admitted for acute inpatient hospital treatment. The patient had become increasingly depressed with suicidal ideation, plan, and intent in the context of heavy alcohol use and severe psychosocial stressors that included primary support and occupational, housing, and social environment domains. The patient was brought to the emergency department by Emergency Medical Services (EMS) with severe symptoms of depression including plan to walk in front of a bus or train; he was using up to a gallon of vodka daily. The patient was homeless beginning five weeks prior to admission in the context of the death of his girlfriend. In the emergency department, he received an evaluation, medical screening, stabilization, and admission for an inpatient level of treatment. At the time of admission, the patient was noted to be severely depressed with persistent suicidal ideation wanting to die, and he had prominent symptoms of alcohol withdrawal with tremors and sinus tachycardia.
The patient's mental status examination revealed a depressed mood with hopelessness, helplessness, anhedonia, and morbid thought content that included thoughts of death and suicidal ideation with the wish to be dead. He was anxious with apprehension, tension, sleep disturbance, irritability, and excessive worry as well as motor retardation and withdrawn behavior. The patient reported morbid thoughts with depressive ruminations and inability to function in the context of the suicidal ideation and hopelessness. There was no evidence of psychosis, perceptual disturbance, mania, or severe cognitive impairment. The patient's sleep, appetite, energy levels, concentration, and volition were disturbed. His insight was fair and his judgment was limited and impaired due to the severity of his depression and associated symptoms of anxiety and alcohol dependence/use.
There were no acute general medical issues in this case other than the alcohol withdrawal. Chronic conditions included fatty liver with hyperlipidemia due to longstanding alcohol use, gastroesophageal reflux disease (GERD), and a history of asthma.
The patient is single, homeless, and had worked as a plumber. He had housing issues and financial strain. There is no history of trauma or legal issues in this case.
The patient was admitted to acute inpatient level services and maintained on close observation with a Librium Clinical Institute Withdrawal Assessment (CIWA) protocol and vitamin replacement therapy. He was treated with Carafate, Omeprazole, Fluoxetine and Quetiapine at therapeutic dosages with titration as clinically appropriate. He was placed on fall, aspiration, and seizure precautions. The patient received counseling and education with motivational techniques, as well as a psychiatric consultation with medication management and plans for transfer to inpatient psychiatric care when stable. He received case management services to address his many psychosocial needs. Discharge plans were made and the patient was transferred to inpatient psychiatric care for continued mental health and substance-related treatment.
The health plan documents, correspondence from the health plan and treatment facility, and the case records were reviewed. The health plan's rationale for denial of coverage of the acute inpatient level services was reviewed with the denial based on medical necessity criteria. This case is New York State mandated review with the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
At issue is the medical necessity of the inpatient level of care.

The requested health service/treatment of inpatient stay was medically necessary for this patient.

The inpatient level of care provided in the context of a severe mood disturbance, alcohol use disorder with acute withdrawal symptoms, and severe psychosocial stressors and high risk for suicidal behavior could not have been safely or effectively provided at a lower level of care in this case scenario. These clinical features warranted inpatient level services and monitoring, as well as efforts to develop a safe and clinically appropriate discharge plan and disposition in concert with case management services and psychiatric consultation with appropriate safety monitoring. The admission and continued inpatient level care through discharge was reasonable in this case scenario and in the best interest of the patient reflecting sound medical judgment with regard to the co-occurring conditions under treatment in this patient.
The inpatient stay was clinically appropriate as he was at high risk for suicide with severe symptoms of depression in the context of a potential for a lethal suicide attempt while using large quantities of alcohol with acute grief and recent homelessness and deterioration in functioning. The patient remained a safety risk and functionally impaired with high risk for relapse if discharged from acute inpatient level care prior to his discharge and transfer. Moreover, the patient needed alcohol detoxification and withdrawal management with monitoring in view of the severity of the alcohol use disorder that included general medical complications (fatty liver and risk for withdrawal seizures).
These answers are consistent with prevailing standards of professional practice, the scientific literature, and published guidelines, referenced below and the clinically appropriate application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.[10]