Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This patient reportedly was admitted to this inpatient hospital for alcohol detoxification treatment. The patient reportedly had alcohol withdrawal symptoms including nausea, elevated heart rate in the 120's, agitation, anxiety, tremors, fasciculations, and had a Clinical Institute Withdrawal Assessment (CIWA) of 16. The patient reportedly was drinking 10-20 shots of whiskey or beer per day. The patient reportedly had a past inpatient detoxification treatment and also a past inpatient alcohol rehabilitation treatment. The patient reportedly was in treatment with outpatient substance treatment twice per week. The patient also reportedly had tried cocaine in the past. The patient reportedly also was in treatment with a psychiatrist and was prescribed Escitalopram for depression and anxiety. The patient reportedly worked as a teacher from home. The patient reportedly was given Diazepam 10 milligrams (mg) and Ativan 2 mg once stat (immediately) and put on a Librium taper 50 mg per day to start for detoxification treatment. The patient reportedly improved and had less withdrawal symptoms the next day and had a CIWA of 3. The patient reportedly left against medical advice (AMA).

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment stating that the patient did not have seizures or delirium tremens (DT's), was not toxic from alcohol or substances, and was not in distress. They stated that the patient did not require 24-hour hospital treatment, and they recommended a less restrictive level of care then.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required this level of care then. The American Psychological 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 reports of active alcohol withdrawal symptoms including nausea, an elevated heart rate in the 120's, agitation, anxiety, tremors, fasciculations, and had a CIWA of 16. The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at risk for severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment then. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.