Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: Inpatient admission.

The insurer denied the inpatient admission. 

The denial was reversed.

This is a male patient who was admitted to inpatient hospital treatment for detoxification. He reportedly had withdrawal symptoms including tremors, nausea, vomiting, agitation, abdominal cramping, headaches, anxiety, sensitivity to light, and he had a CIWA of 15. He reportedly had blackouts. He reportedly was drinking 12 beers per day. He also reportedly was using $700 of cocaine 1-3 times in a month. He reportedly had a positive toxicology for benzodiazepines. He reportedly had multiple past inpatient detoxification and rehabilitation treatments. He reportedly was homeless as his wife kicked him out. He took Ativan for detoxification and then preferred Valium for detoxification He was medically stable the patient accepted a referral to inpatient rehabilitation treatment. 
 
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 large amounts daily including drinking 12 beers per day in addition to cocaine use.  He was in active withdrawal including tremors, nausea, vomiting, agitation, abdominal cramping, headaches, anxiety, sensitivity to light, and he had a CIWA of 15 so he was at risk for more severe, complicated, and life threatening withdrawal. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use alcohol daily with a 33 year history. He also required and needed detoxification medication including Ativan and Valium to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then. Also, he likely would have relapsed again as evidenced by relapsing after past treatments. He reportedly was in active withdrawal with a CIWA of 15 on admission and then he had reports of continued withdrawal with a CIWA of 11, and then had some withdrawal symptoms a couple of day prior to discharge. He took detoxification medication and was discharged with a referral to inpatient rehabilitation treatment. He was homeless as his wife reportedly kicked him out. It was unlikely that he would remain abstinent while still having withdrawal symptoms so 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 and also to prevent possible life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time. 

It did not appear that the health care plan acted reasonably or in the best interest of the patient.  

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.