Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a male admitted to inpatient hospital treatment for detoxification from alcohol. He reportedly had withdrawal symptoms including tremors, anxiety, hypertension with a blood pressure of 157/100, and tachycardia. He was homeless and lived in shelters. He had herniated discs. He reportedly had depressive and anxiety symptoms and was taking Paxil, Duloxetine, Gabapentin, Hydroxyzine, and Trazodone. He was put on an Ativan protocol and taper. He was discharged.

The insurer denied coverage for inpatient hospital treatment for detoxification as not medically necessary.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment for detoxification as the chart notes provided enough specific evidence to support that he was in need of hospital treatment then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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, hypertension with a blood pressure of 157/100, and tachycardia, and was at risk for worsened withdrawal symptoms including severe, complicated, or life threatening withdrawal and he required and received detoxification medication including Ativan 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 an outpatient detoxification settings as he continued to use alcohol despite recent past treatment as it was reported that he was admitted to this hospital after just being discharged. Also, he required and needed detoxification medication to modify withdrawal and to prevent more serious withdrawal as it was reported that he had an Ativan taper and on a specified date he reportedly received Ativan and still was on an Ativan taper. Notes on another date reported that he continued with the Ativan taper protocol.  It was not likely that he could safely be managed in an outpatient setting then and he lacked supports. He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting. 

As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient detoxification treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

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