Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Active alcohol withdrawal symptoms
Treatment: inpatient substance/alcohol detoxification treatment
The insurer denied coverage for: inpatient substance/alcohol detoxification treatment
The denial is: Overturned
This adult patient was admitted to this inpatient substance/alcohol detoxification treatment. The patient had alcohol withdrawal symptoms including sweats, tachycardia, palpitations, nausea, vomiting, tremors, anxiety, irritable mood, insomnia, headache, auditory and visual disturbance, and had a Clinical Institute Withdrawal Assessment (CIWA) of 14. The patient reportedly also had a positive history for alcohol withdrawal seizures. The patient had a positive toxicology for benzodiazepines and ethyl glucuronide and a past positive toxicology for cocaine. The patient also had comorbid depression. The patient had a past inpatient detoxification treatment including a recent one. The patient was put on a Librium taper for detoxification treatment, was monitored with a pulse ox, and vital signs were monitored. The patient was discharged 5 days later.

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. 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 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. The patient had a long history of alcohol use including a 42-year history and also had reports of past cocaine use. The patient had reported diagnoses of Alcohol and Cocaine Use Disorder and was at risk also for medical issues related to that and also overdose. The risk of life complicated withdrawal such as delirium tremens increases 3-4 days after alcohol use so the patient required inpatient detoxification treatment and was considered at high risk medically for severe, complicated, and life-threatening withdrawal. The patient had a past alcohol withdrawal seizure and the standard treatment is for inpatient hospital detoxification treatment when one has a history of alcohol withdrawal seizure.  

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 the inpatient detoxification admission is substantiated.