Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is a male patient with prior history of bipolar disorder, depression, schizoaffective disorder, crack cocaine use and alcohol dependency who was admitted for inpatient hospital detoxification treatment for alcohol and substance detoxification. He had withdrawal symptoms including tremors, difficulty sleeping, anxiety, and he was started on a Librium protocol. On day 3 of admission, the patient left Against Medical Advice (AMA) instead of completing detoxification. He also did not agree with the referral for inpatient alcohol/substance rehabilitation after the detoxification treatment. He reportedly had multiple past inpatient substance/alcohol detoxification treatments and also had past inpatient substance/alcohol rehabilitation treatment. He reportedly was drinking 2-3 pints of liquor per day and also drinking 40 ounces of beer, and using crack/cocaine and alcohol for many years, and using 2 joints per day 1-2 times per week.  He reportedly had past psychiatric hospital treatment for a suicide attempt and depression. He did not have stable housing.

The insurer denied coverage for the inpatient hospital detoxification 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 reports that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens 3-4 days after cessation of use. It also states that patients with comorbid medical conditions complicating that management of withdrawal are candidates for inpatient hospital treatment.  

In this case this patient had active alcohol withdrawal symptoms including tremors, anxiety, and insomnia and was at risk for worsened withdrawal symptoms including severe, complicated, or life threatening withdrawal and he required and received detoxification medication including Librium to modify withdrawal and prevent worsened withdrawal. He reportedly was at risk for severe, life threatening, and complicated withdrawal including withdrawal seizures or delirium tremens as delirium tremens can occur 3-4 days after cessation of alcohol use.  

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 detoxification settings as he continued to use large amounts of alcohol, crack/cocaine, and cannabis despite multiple past inpatient detoxification and inpatient rehabilitation treatment. Also, he required and needed detoxification medication to modify withdrawal and to prevent more serious withdrawal. He also did not agree with the referral for inpatient alcohol/substance rehabilitation after the detoxification treatment. It was not likely that he could safely be managed in an outpatient setting or a less restrictive setting other than a hospital detoxification setting as he was a high risk patient. He lacked stable housing and supports. He needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting, including severe and life threatening withdrawal symptoms, and this risk is high from 3-4 days after alcohol use. 

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

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