Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment Medically Supervised Inpatient Detoxification

The insurer denied coverage for Medically Supervised Inpatient Detoxification

The denial is overturned

This patient was admitted to inpatient substance/alcohol detoxification treatment for detoxification from alcohol. She reportedly had a Clinical Institute of Withdrawal Assessment (CIWA) of 9 and had withdrawal symptoms including hot and cold sweats, anxiety, and irritability. She reportedly was drinking 1/5 of liquor and beers daily and smoking 3 joints per day. She had a positive toxicology for THC (tetrahydrocannabinol). She had multiple past inpatient detoxification and rehabilitation treatments and could not maintain abstinence. She reportedly was unemployed. She reportedly had past psychiatric hospitalizations including for aggression and had been noncompliant with her psychotrophic medications, Risperidone and Mirtazepine. She reportedly was put on a Librium 5-day protocol taper for detoxification. She reportedly signed out against medical advice (AMA).
    
This reviewer disagrees with the decision to deny coverage for inpatient substance/alcohol detoxification medically supervised treatment as the medical records provided enough specific evidence to support that she required this level of care. 

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 (United States) 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 active alcohol withdrawal symptoms including hot and cold sweats, anxiety, and irritability with a CIWA of 9. She reportedly had a large amount of daily alcohol use including drinking 1/5 of liquor and beers daily and smoking 3 joints per day with a 26-year history and was considered at risk for severe, complicated, and life-threatening withdrawal.  

The inpatient substance/alcohol detoxification medically supervised treatment was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.

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

The insurer's denial of coverage for the Medically Supervised Inpatient Detoxification admission is overturned. Medical Necessity is substantiated.