201907-118797
2019
Fidelis Care New York
Medicaid
Substance Abuse/ Addiction
Substance Abuse: Inpatient
Medical necessity
Overturned
Case Summary
Diagnosis: Substance Detoxification
Treatment: Inpatient Substance Detoxification
The insurer denied the Inpatient Substance Detoxification.
The denial was reversed.
This is a male patient was admitted to inpatient substance detoxification in early 2019 for alcohol detoxification. In early 2019 he reportedly had withdrawal symptoms including increased heart rate and blood pressure with a heart rate of 105 and blood pressure of 138/77. He also had reports of sweats, joint pain, sleeping problems, and anxiety with a CIWA of 7. He reportedly was drinking six 12 ounce beers per day and had past blackouts. He has had past inpatient detoxification a couple of years ago and 2 past treatment episodes without prolonged abstinence. He has depression and anxiety and was taking Zoloft and Zyprexa. He lacked coping skills and needed to better identify triggers. It was reported that he was at risk of losing housing. He was started on a Librium protocol for detoxification. The plan was for inpatient substance rehabilitation treatment, he was discharged a few days after his initial admission.
The 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. This patient had been drinking alcohol daily and had alcohol withdrawal symptoms. According to the 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 past inpatient detoxification, and he required and needed detoxification medication (Librium) to modify withdrawal and needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms.
Patient documentation from admission reported that he was given detoxification medication, Librium, for modification of withdrawal. Further documentation reported that he still had withdrawal symptoms including sweating and anxiety and was responding to the detoxification protocol. It was unlikely that he would have remained abstinent while still having 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 of hospital stay.
The carrier's denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.