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 male patient who was admitted to inpatient hospital treatment for detoxification.  He had alcohol withdrawal symptoms and was put on a Librium protocol.  He reportedly was drinking alcohol, using cocaine and cannabis.  He had multiple medical issues including diabetes, hypertension, gastritis, gastroesophageal reflux disease (GERD), and coronary artery disease.  He had a psychiatric history significant for schizoaffective disorder-bipolar type and was taking Risperidone and Zoloft.  He reportedly continued reporting withdrawal symptoms until discharge.  He was referred to an Alcohol Treatment Center (ATC) for alcohol/substance rehabilitation treatment upon discharge. 

The decision to deny coverage for inpatient hospital treatment for detoxification should be overturned, 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 active withdrawal symptoms and had reportedly been drinking alcohol and was at risk for more severe, complicated or life threatening withdrawal.  He also reportedly was using cocaine and cannabis.  He had multiple medical issues, also, including diabetes, hypertension, gastritis, GERD, and coronary artery disease.  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, as he continued to use alcohol despite medical issues and comorbid psychiatric symptoms, and he required and needed detoxification medication, Librium, to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal.  He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life threatening withdrawal symptoms.  It was reported that he had withdrawal symptoms of tremors, sweats, and anxiety and was still on the Librium protocol.  It was reported on day 3 of admission that he had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 9 and had withdrawal symptoms including tremors, sweats, agitation, and anxiety and was still on the Librium protocol.  It was reported on day 4 of admission that he still had withdrawal symptoms including agitation and anxiety and was still on the Librium protocol.  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 in this hospital.

Inpatient substance detoxification in this hospital was medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

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