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Alcohol Detox

Disputes about substance abuse frequently related to the necessity of inpatient care, and especially the number of days necessary for detoxification. A 40-year-old severely alcoholic woman received care at a residential treatment center from Dec. 8 to Jan. 6. The HMO approved only the first five days of her stay, denying the treatment she received from Dec. 13 onward. The Independent Review, Inc. reviewer overturned this decision, emphasizing the severity of her addiction.

The reviewer notes that the woman had been drinking a fifth of vodka every day for two years. When she came into the treatment facility she admitted to drinking daily since she was 20-years-old, with the exception of a two and one-half year period of sobriety. Furthermore, she and members of her family had a history of depression, and she also tried to commit suicide after her mother's death.

During detoxification, she suffered from hypertension, shaking, elevated blood pressure and pulse rate, and a seizure. She remained on several different medications to help her cope with these symptoms until Dec. 13, then began to think more clearly on Dec. 14.
The insurance company doctor stated her conditions could have been treated on an outpatient basis. The reviewer firmly disagreed, stating that the details of her medical report clearly indicated that she had "severe alcohol dependence syndrome." The severity of her problem was complicated by the fact that she had a dual diagnosis with major depression requiring antidepressants. The reviewer concluded that she had been discharged on "step four," a very important step for her to complete.
While she was motivated to do her work in the rehabilitation program, she continued to have much resentment that would have likely led to relapse. Therefore, the five days of treatment approved by the HMO was an inadequate time period for this patient's recovery.
Source: Independent Review, Inc., IRO Decision Letter, Prinicipal Life Insurance, April 12, 2001.