Diagnosis: withdrawal symptoms

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned.

This male patient has a history of alcohol use disorder, opioid use disorder in remission, and depression.

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.
The 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.
According to the Level of Care for Drug and 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 large amounts of alcohol, needed detoxification medication including Librium and needed one day of observation without withdrawal symptoms or detoxification medication as he was considered a high risk for more severe withdrawal, complicated, and even life threatening withdrawal such as delirium tremens due to his large amount of daily alcohol use. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the time in this hospital setting for detoxification as he was discharged to an inpatient rehabilitation treatment.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.