Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use and bipolar disorder.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient who was admitted for inpatient detoxification treatment. His withdrawal symptoms included tremors, nausea, vomiting, agitation, anxiety, sleeping problems, headache, and irritable mood. He was reportedly drinking 1 pint of alcohol, smoking crack/cocaine, and smoking cannabis daily. The patient reportedly had multiple past inpatient substance detoxification treatments including a recent one in which he relapsed on the day of discharge. He also had comorbid bipolar disorder. The patient's Clinical Institute Withdrawal Assessment (CIWA) for Alcohol score on admission was 13. He was admitted and treated via a Librium taper protocol. He was stabilized and discharged to aftercare rehabilitation program on day 5 of admission.

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 active withdrawal symptoms on admission including a CIWA for Alcohol score of 13 and he continued to have withdrawal symptoms during the inpatient course. 

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 in an outpatient detoxification setting as he continued to use alcohol daily as well as crack/cocaine and cannabis despite reports that he had multiple previous inpatient substance detoxification treatments and still relapsed (i.e. the day of discharge after his last admission for detoxification). The patient also required and needed detoxification medication to modify his withdrawal symptoms, and needed 24-hour treatment and monitoring as he was at risk for complicated and life-threatening withdrawal with his heavy polysubstance use. Notes on admission reported that the patient's CIWA for Alcohol score was 13 with withdrawal symptoms including tremors, nausea, vomiting, agitation, anxiety, sleeping problems, headache, and irritable mood, for which the patient was put on a Librium taper. In addition to withdrawal symptoms, the patient had a comorbid diagnosis of bipolar disorder. It was unlikely that the patient would remain abstinent while still having withdrawal symptoms. Thus, the patient required the time in this inpatient detoxification treatment setting to treat his withdrawal symptoms and decrease the chance of relapse again. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required the entire admission course.

The inpatient substance detoxification 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. 

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.