Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. The denial was overturned. 

This is a male patient who was admitted to a facility for inpatient substance treatment for detoxification and rehabilitation treatment. The patient reportedly had withdrawal symptoms including sweats, tremors, headache, and diarrhea. The patient was put on a detoxification protocol. The patient's urine toxicology was positive for opiates. The patient reportedly lacked coping skills to remain sober and had not had abstinence for many years. The patient reportedly had multiple inpatient detoxification and rehabilitation treatments. The patient also had comorbid depression and anxiety and had comorbid medical issues including hypertension, cerebrovascular accident (CVA), and asthma. The patient was unemployed and was a widow. The patient reportedly 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. 

In this case, this patient had withdrawal symptoms and was drinking large amounts of alcohol daily which put him at risk for severe, complicated, and life threatening withdrawal. This clinical presentation required days of detoxification treatment in the hospital. After inpatient detoxification, the patient required inpatient substance/alcohol rehabilitation treatment as he continued to use large amounts of alcohol despite multiple inpatient detoxification and rehabilitation treatments in the past. The patient reportedly lacked coping skills to remain sober and had not achieved abstinence for many years. The patient was not able to identify relapse triggers, and was unemployed and was a widow. These circumstances indicated that this patient was at high risk for relapse. 
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification or rehabilitation in a less restrictive setting as he continued to use large amounts of alcohol daily despite multiple inpatient detoxification and rehabilitation treatments in the past. At the time of admission, the patient needed detoxification protocol to prevent more severe, complicated, and life threatening withdrawal. The patient presented with active withdrawal symptoms including sweats, tremors, headache, and diarrhea. The patient's risk of delirium tremens was 3-4 days after his last alcohol use. 

Based on the review of the medical record and literature, inpatient detoxification was medically necessary for this patient as this patient was considered a high risk for relapse in a less intensive level of care and treatment. The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the hospital admission should be overturned. The medical necessity is substantiated.