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

This is a male patient who was admitted to inpatient alcohol detoxification treatment for alcohol detoxification. He had withdrawal symptoms including tremors. He was drinking large amounts of alcohol daily. He had past inpatient detoxification and inpatient rehabilitation treatment and continued to relapse. He had past blackouts. It was reported that he had a sad mood, fatigue, and poor insight. His alcohol use reportedly interfered with family relationships and finances. He was put on a Librium taper protocol and given Ativan as needed for alcohol detoxification treatment, as well as Campral, thiamine, folic acid, and multivitamin. He was discharged with a referral to outpatient rehabilitation 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, 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 been using large amounts of alcohol daily and had active withdrawal including tremors which put him at risk for severe, complicated, and life threatening withdrawal.

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 for detoxification in a less restrictive setting as he continued to use very large amounts of alcohol daily despite past inpatient detoxification and inpatient rehabilitation treatment, needed detoxification medications including Librium and Ativan for detoxification, and continued to drink large amounts of alcohol daily despite negative consequences from alcohol interfering with relational issues, finances, and medical issues. He reportedly lacked the coping skills to stop alcohol use and needed 24 hour hospital detoxification as he was considered a high risk medically. He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens which could occur 4 days after alcohol use so he required the entire hospital treatment. This was a high risk patient who had withdrawal symptoms and was considered a high risk medically for severe, complicated, and life threatening withdrawal.

Inpatient hospital detoxification treatment was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient then.

The carrier's denial of coverage for the inpatient detoxification treatment services is overturned. The medical necessity is substantiated.