Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance detoxification Treatment

The insurer denied the Inpatient Substance Detoxification Treatment.  The denial was reversed.  

This is a male patient with a history of two past reported inpatient substance detoxification treatments and one past reported inpatient substance rehabilitation treatment.  He presented to a rehabilitation facility for alcohol and benzodiazepine detoxification.  He reported drinking 4-5 shots per day, using 2 mg of benzodiazepines, and smoking 1 gram of cannabis 3-6 times per week.  His withdrawal symptoms included nausea, teary eyes, anxiety, and sleeping problem.  He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 9.  He was treated with a Librium protocol and after a couple days of treatment he left against medical advice (AMA). 

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. 

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 outpatient detoxification settings as he continued to use large amounts of alcohol and benzodiazepines putting himself at risk of severe and life threatening withdrawal despite two past reported inpatient substance detoxification treatments and 1 past reported inpatient substance rehabilitation treatment.  Also, he required and needed detoxification medication of Librium twice the first two days and once on the last day to modify withdrawal and to prevent more serious withdrawal and complicated or life threatening withdrawal.  This patient could not safely be treated in an outpatient detoxification as he reportedly had active withdrawal symptoms including nausea, teary eyes, anxiety, sleeping problems, and had a CIWA of 9 and was at risk for more severe, complicated, or life threatening withdrawal including delirium tremens (DT's).  It is reported that delirium tremens can occur within 3-4 days after stopping alcohol use.  This patient was having withdrawal symptoms on admission so he was in active withdrawal and at risk for complicated and life threatening withdrawal symptoms 3-4 days after admission as he was considered a high risk.  Thus, he was in need of the inpatient alcohol detoxification treatment as a result.  He left AMA but he received detoxification medication while in treatment.  He also reportedly lacked coping skills, sober supports, and ability to identify relapse triggers so he required 24 hour inpatient detoxification treatment as he could not safely and effectively be treated in a less restrictive setting then.  He required medical inpatient detoxification due to his high risk for worsened and life threatening withdrawal. 

It did not appear that the health care plan acted in the best interests of the patient then or with sound clinical judgment or reasonably then.

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