Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use. 

Treatment: 5 Days/Units of Inpatient Substance Abuse Services.

The insurer denied coverage for 5 Days/Units of Inpatient Substance Abuse Services.

The denial is overturned. 

The patient is a male who was admitted to inpatient hospital treatment for alcohol detoxification. The patient reportedly had withdrawal symptoms including tremors, nausea, decreased appetite, sleep disturbance, malaise, muscle cramps, low energy, and he had a past reported alcohol withdrawal seizure 6 months prior to admission. The patient reportedly had been drinking multiple pints of hard liquor per day and had alcohol use since a young age. The patient also had visual hallucinations and reported them when drinking alcohol. The patient's psychiatric history was significant for schizophrenia and past reported psychiatric hospitalization. The patient had multiple past inpatient detoxification and rehabilitation treatments as well as outpatient alcohol treatments; yet, still the patient relapsed. The patient was recently incarcerated and released from jail, one week prior to admission. The patient was homeless, unemployed, and lacked supports. The patient had a positive toxicology for benzodiazepines. The patient was admitted and was placed on Ativan for detoxification throughout the hospitalization. The patient also had medical issues. The patient also took Zoloft, Depakote, and Seroquel, as well as thiamine, folic acid, and Campral.
  
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 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 reported alcohol withdrawal seizures which require inpatient medical detoxification treatment.   

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily, required and received detoxification medication (Ativan) to modify withdrawal from alcohol and prevent another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so this patient was considered at high risk for severe, complicated, and life threatening withdrawal. It was still reported that the patient took Ativan throughout the hospitalization and it was reported that he took Ativan 1 milligram (mg) still due to withdrawal. The patient also continued to use large amounts of alcohol despite multiple past inpatient detoxification and rehabilitation treatments as well as outpatient alcohol treatments and despite negative consequences including incarceration. The patent also lacked supports and was homeless. The patient required 24-hour inpatient medical hospital treatment for alcohol detoxification and it was considered unsafe for the patient to be treated for detoxification in a less restrictive level of care. Thus, inpatient substance abuse services were 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 5 Days/Units of Inpatient Substance Abuse Services is substantiated. The insurer's denial should be overturned.