Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal
Treatment: Inpatient hospital treatment
The insurer denied coverage for: Inpatient hospital treatment
The denial is : Overturned
This adult patient was admitted to this inpatient hospital due to alcohol withdrawal symptoms. The patient was helpless as they could not stop alcohol use on their own. The patient reportedly had a past history of alcohol withdrawal seizures and delirium tremens (DT's). The patient was drinking 1 quart of vodka per day, had suicidal ideation with a plan to cut themself with a razor. The patient had past psychiatric hospitalizations and past suicide attempts including past overdose of Xanax. The patient received intravenous (IV) Valium and Librium taper for alcohol detoxification treatment. It was reported that the patient was discharged 2 days later.
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required this level of care. 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. Also, the United States (US) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow-up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had reports of alcohol withdrawal with a history of alcohol withdrawal seizure and past delirium tremens, the patient was considered at high risk medically for life threatening withdrawal including delirium tremens again, the patient required this inpatient hospital detoxification treatment level of care. The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at high risk for severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient did require 24-hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting as the patient continued to use large amounts of alcohol daily. The patient did require 24-hour inpatient medical hospital treatment for alcohol detoxification, and it was considered unsafe for the patient to be treated for detoxification in a less restrictive level of care. The patient was considered a high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment and also had comorbid psychiatric issues including current suicidal plan to cut themself and had past suicide attempts and psychiatric hospitalizations as well as depression. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.