Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use
Treatment: Inpatient substance abuse detoxification
The insurer denied coverage for the inpatient substance abuse detoxification.
The denial is overturned. 

This is a male patient, who was admitted for alcohol detoxification.  He reportedly had withdrawal symptoms including tremors, nausea, vomiting, agitation, anxiety, irritable mood, sweats, headaches, disorientation to time, and tactile disturbances with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score as high as 18.  He reportedly was drinking beer daily, and using crack/cocaine and cannabis/hashish.  He reportedly had a positive toxicology for cocaine and benzodiazepines.  He reportedly was put on a Librium protocol for detoxification.  He also had reports of psychiatric hospitalizations, as he had diagnoses of post-traumatic stress syndrome (PTSD) and bipolar disorder.  He reportedly was taking Seroquel.  He was discharged on day 6 of admission with a referral for outpatient 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, currently abuse other substances, or who have 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 alcohol daily and was also using crack/cocaine, and cannabis/hashish daily, and his toxicology was positive for cocaine and benzodiazepines, as well, which put him at risk for overdose as well as severe, complicated, and life threatening withdrawal.  He also had psychiatric comorbidity with PTSD and bipolar disorder, as he had reports of severe trauma.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment, as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use alcohol daily and had active withdrawal symptoms including tremors, nausea, vomiting, agitation, anxiety, irritable mood, sweats, headaches, disorientation to time, and tactile disturbances with a CIWA score as high as 18, which put him at high risk for complicated and life threatening withdrawal, which required 24-hour hospital detoxification treatment then.  It was reported that he had the detoxification medication, Librium.  He continued to have reports of alcohol withdrawal as notes on day 3 of admission reported tremors, agitation, and anxiety. 

Notes on day 4 of admission reported tremors and sweats.  Notes on day 5 of admission reported tremors, agitation, anxiety, irritable mood and a CIWA score still as high as 9.  The patient was considered at high risk while still reporting alcohol withdrawal symptoms during the denial period and while still being treated with Librium for detoxification treatment.  He had psychiatric comorbidities and was using other serious substances daily including crack/cocaine.  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 was medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

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