Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient hospital stay

The insurer denied the request for the inpatient hospital stay 

The denial was overturned.   

This male patient was admitted for inpatient hospital detoxification. He has a medical history of asthma, diabetes, cardiac murmur, fibula fracture, and substance use. He had alcohol withdrawal symptoms including tremors, agitation, anxiety, headache, and restlessness. He had a Clinical Institute Withdrawal Assessment (CIWA) of alcohol score of 11. The patient reported drinking 12 beers per day, using $300 worth of cocaine daily, and using $50 worth of cannabis daily. He had a positive toxicology for cocaine. He was homeless and had a history of seizure and blackout. The patient was found to have a urinary tract infection (UTI) requiring treatment with an antibiotic. He was put on a Librium protocol for his detoxification and discharged with a referral to a rehabilitation facility. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders states that patients with failure to achieve abstinence or patients who relapse frequently, failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, and heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. 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. Patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. The United States Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports inpatient treatment is necessary if the ability to attend outpatient treatment daily or follow up in outpatient treatment is a problem, medical conditions complicate withdrawal treatment, one has previous withdrawal seizures of delirium tremens, or if there is no capacity for informed consent. 

This patient had been drinking large amounts of alcohol daily and using large amounts of cocaine and cannabis, putting him at higher medical risk for overdose or more severe and life threatening withdrawal. The history of seizure and blackout further put him at high risk for more severe withdrawal or seizure. The patient had also had multiple medical issues. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment and could not safely and effectively be treated in an outpatient detoxification setting. 

The patient continued to report withdrawal symptoms throughout his hospital stay, including moderate tremors and anxiety, sweating, and agitation. He remained on the detoxification protocol. Based on this patient's history and risk factors, it was unlikely that the patient would remain abstinent while still having withdrawal symptoms in a setting less intensive than an inpatient level of care. This treatment setting was required to stop his withdrawal symptoms and decrease the chance that he would relapse again when not in this 24-hour setting as well as to prevent possible life-threatening withdrawal symptoms. The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so the patient required the entire admission time in this hospital detoxification setting with a referral to a rehabilitation facility. The patient lacked supports and was homeless. Thus, inpatient admission was medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The denial of coverage for inpatient admission is overturned. The medical necessity is substantiated.