Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient detoxification

The insurer denied coverage for inpatient detoxification
The denial is overturned

This patient was admitted to an inpatient hospital detoxification treatment. He reportedly had withdrawal symptoms including tremors, sweats, chills, nausea and vomiting, agitation, anxiety, and he had a clinical institute withdrawal assessment for alcohol (CIWA) score of 15. He reportedly had multiple inpatient detoxification treatments (at least 12 reported) and inpatient rehabilitation treatments and still was unable to stop his large amount of daily alcohol use and cocaine use. He reportedly had hepatitis C, hypertension, asthma, osteoarthritis, and back pain. 
  
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. In this case this patient had been drinking large amounts of alcohol daily including two to six packs of beer per day and cocaine/crack daily and was at risk for severe, complicated, and life-threatening withdrawal due to this large amount of daily alcohol use, so he required 24-hour inpatient hospital detoxification treatment as he was at risk medically. 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 less restrictive detoxification settings as he continued to use large amounts of alcohol daily despite multiple past inpatient detoxification treatments and rehabilitation treatments and he required and took detoxification medication, Librium, to modify and treat withdrawal. He needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life-threatening withdrawal symptoms. It was reported that he had detoxification medication, Librium throughout his stay. He also had comorbid bipolar disorder with a past psychiatric hospitalization and 2 past suicide attempts which put him at further risk of harm to self. He reportedly lacked supports and was living by himself and was unemployed, lacked coping skills for abstinence and lack relapse prevention skills. He could not maintain abstinence so he could not safely and effectively be treated in a less restrictive level of care then. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this medical inpatient detoxification setting. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance/alcohol detoxification. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.  

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