Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use; withdrawal symptoms

Treatment: Substance use medically supervised inpatient rehabilitation

The insurer denied coverage for substance use medically supervised inpatient rehabilitation. The denial reversed.

This patient is a male who was admitted to this inpatient hospital treatment for inpatient withdrawal management. He had withdrawal symptoms including nausea, tremors, sweats, elevated heart rate of 105, anxiety, teary eyes, irritable mood, and sleeping problems. He was drinking large amounts of alcohol daily including 2 pints of liquor and 25 beers per day, and was smoking crack and cannabis per day. He had multiple past detoxifications in recent years. He took Sertraline. He was given Librium for withdrawal management for a specified range and was then discharged.

The insurer denied coverage for this inpatient substance use medically supervised hospital treatment for inpatient withdrawal management as not medically necessary treatment then. This reviewer disagrees with the decision to deny coverage for inpatient substance use medically supervised hospital treatment for inpatient withdrawal management as the chart notes provided enough specific evidence to support that he required 24-hour hospital treatment for detoxification. 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. In this case, this patient had been drinking very large amounts of alcohol daily and had active withdrawal symptoms. He was at risk for more severe, complicated, and life- threatening withdrawal symptoms and required 24-hour inpatient substance hospital treatment for 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. This was evidenced by the fact that he continued to use very large amounts of alcohol and was smoking crack and cannabis daily with multiple prior inpatient detoxification treatments. Also, he required and needed detoxification medication including Libriumto modify withdrawal. He needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms. It was unlikely that he would remain abstinent while having withdrawal symptoms; therefore, he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24-hour setting.

The risk of complicated withdrawal such as delirium tremens can occur 4 days after alcohol use; therefore, he required the entire time in the inpatient setting. He also did not have the coping skills to maintain abstinence and to be treated in a less restrictive setting other than this inpatient detoxification hospital treatment, as he could not stop substance use outside of a 24-hour hospital setting. As a result, reverse the previous decision and approve coverage for inpatient substance hospital treatment for medically supervised inpatient withdrawal management. The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient.   

Based on the above, the medical necessity for the substance use medically supervised inpatient rehabilitation is substantiated.  The insurer's denial is reversed.