Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
Treatment: Inpatient hospital admission
The insurer is denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a male patient who was admitted to inpatient hospital treatment after having a seizure due to alcohol withdrawal. The patient reportedly was confused after the seizure. His withdrawal symptoms included elevated heart rate of 108, elevated blood pressure of 140/99, tremors, shakes, headache, anxiety, and tingling. The patient reported drinking 1 pint of vodka per day. The patient's toxicology was positive for tetrahydrocannabinols (THC). During inpatient stay, the patient was treated with 2 detoxification medications including Ativan and Librium. After treatment, the patient was cleared for discharge.

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 states that patients with current or 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 and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent.

In this case this patient had complicated severe withdrawal as he had an alcohol withdrawal seizure and required 24 hour medical detoxification treatment in the hospital as a result. The patient was at risk of even more severe and life threatening withdrawal symptoms including delirium tremens. At the time of hospital presentation, the patient had active withdrawal symptoms including elevated heart rate of 108, elevated blood pressure of 140/99, tremors, shakes, headache, anxiety, and tingling and had withdrawal seizure from alcohol which required inpatient medical detoxification treatment. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24-hour treatment as he could not have been safely and effectively treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily, required and received 2 detoxification medications (Ativan and Librium and had intravenous (IV) and IM Ativan as well) to modify his withdrawal from alcohol and prevent another withdrawal seizure of more complicated or life threatening withdrawal such as delirium tremens.  Thus, based on the review of the medical record and literature, inpatient admission was medically necessary for this patient's alcohol detoxification.

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

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