Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a female patient who was admitted for inpatient hospital treatment for detoxification.  The patient presented with active alcohol withdrawal symptoms including tremors, agitation, anxiety, headache, and had a Clinical Institute Withdrawal Assessment (CIWA) of Alcohol score of 8.  The patient reportedly was drinking large amounts of alcohol and fell down prior to hospital presentation.  The patient also had a past admission for similar reasons.  The patient had multiple medical issues. The patient was also homeless.  The patient was admitted and treated on a Librium taper protocol.  The patient was noted to be uncooperative and agitated and then, 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.  In this case, this patient had active withdrawal symptoms including tremors, agitation, anxiety, headache, and had a CIWA of Alcohol score of 8, and had several comorbid medical conditions complicating the management of her withdrawal. Thus, the patient required inpatient hospital detoxification treatment then.  The patient also had multiple medical issues including uncontrolled diabetes, hypokalemia, a heart rhythm disorder, and low hemoglobin and hematocrit levels. The patient also had high blood pressure.  The patient was appropriately admitted and treated with Librium taper protocol.  Notes on day 2 of admission reported that the patient continued to experience withdrawal symptoms including nausea, diaphoresis, and tremors, with a CIWA score of 5 and was still on the Librium taper. Notes on day 3 of admission reported that the patient was uncooperative and her CIWA score was unable to be obtained, and she left AMA.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as she could not safely and effectively be treated in less restrictive detoxification settings as she continued to use alcohol as well as cocaine and cannabis as her toxicology was positive for cocaine and tetrahydrocannabinol (THC) in addition to her heavy alcohol use.  The patient also required and needed detoxification medication, Librium, to modify her withdrawal symptoms and needed 24-hour treatment as she was at risk for worsened withdrawal symptoms including complicated and life threatening withdrawal.  It was unlikely that the patient would remain abstinent while still having withdrawal symptoms so she required the time in this inpatient detoxification treatment setting in order to stop withdrawals and decrease the chance that she 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.

The inpatient substance detoxification was medically necessary for this patient.

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 inpatient hospital admission should be overturned.  The medical necessity is substantiated.