Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance abuse
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is modified. 

This patient is a male who was admitted to this inpatient hospital treatment. This patient was noted to be severely underweight with BMI of 14.5, and severely malnourished with muscle wasting. The patient's medical history was significant for immunocompromised status, chronic obstructive pulmonary disease (COPD), and polysubstance abuse. The patient was homeless, and had decline in functional status, such as poor activities of daily living. The patient reported using drugs and alcohol intermittently. On examination, the patient was noted to be drowsy and difficult to converse with. The patient had withdrawal symptoms consistent with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 11, which increased to 14 by the time of admission. The patient was prescribed Ativan, Librium, and Methadone for detoxification. The patient was also given antibiotic for his urinary tract infection.  The patient was seen by a Psychiatric consultant who recommended Olanzapine for untreated Bipolar disorder in addition to his alcohol, heroin, and cocaine use disorder.  The patient was then discharged to a subacute rehabilitation.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that the 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, and comorbid medical conditions complicating the management of withdrawal are candidates for inpatient detoxification treatment.  APA also reports that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens 3-4 days after cessation of use.  

In this case this patient had active withdrawal symptoms and had a CIWA increase from 11 to 14 and the patient was prescribed detoxification medication to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal symptoms.  The patient requested detoxification and had co-morbid medical conditions, such as severe underweight (BMI 14.5), and severe malnourishment with muscle wasting. The patient was at risk for severe, life threatening, and complicated withdrawal including withdrawal seizures or delirium tremens due to his immunocompromised status and his daily intake of large amounts of beer and heroin use.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as the patient could not safely and effectively be treated in the outpatient detoxification settings with this patient's continued use of large amounts of alcohol and heroin as well as cocaine despite his serious medical issues. The patient required inpatient detoxification medication to modify withdrawal and to prevent more serious withdrawal associated with his co-morbid medical conditions.  Based on the review of the medical record, this patient required inpatient detoxification treatment for a specified date range. However, based on the notes from another specified date range there was insufficient clinical evidence that this patient required continued hospital treatment for detoxification or psychiatric reasons.

The carrier's denial of coverage for the inpatient hospital services is modified.