Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute pancreatitis due to alcohol use

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This patient was admitted to this hospital with acute pancreatitis due to alcohol use and had alcohol detoxification treatment as he had reports of alcohol withdrawal including nausea, multiple episodes of vomiting, shakes, fatigue, insomnia, loss of appetite, weakness, and elevated heart rate. He reportedly had 4-5 drinks but was averaging 7-9 drinks of bourbon per day. He reportedly had multiple medical issues due to alcohol use including pancreatitis, acute transaminitis, low potassium (K) of 2.7 and low magnesium (MG) requiring supplementation and intravenous (IV) fluids. He reportedly had hepatomegaly and thrombocytopenia with a platelet level of 57 and also had a prolonged QT (interval on electrocardiogram [EKG]) interval. He was started on Librium for detoxification which was then changed to Ativan for detoxification. He reportedly required and received Ativan for alcohol detoxification treatment and then was discharged with referral to outpatient treatment. 

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment, for the medical records provided enough specific evidence to support that he required this hospital level of care. 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. Also, the United States (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. In this case this patient had comorbid medical conditions complicating the management of withdrawal, as he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment. 

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 large amounts of alcohol daily, required and received IV detoxification medication (Lorazepam and Librium initially) to modify withdrawal from alcohol and prevent more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at high risk for this. He also had multiple medical issues due to alcohol use including acute pancreatitis, acute transaminitis, low K of 2.7 and low MG requiring supplementation, hepatomegaly, thrombocytopenia with a platelet level of 57 and also had a prolonged QT interval. These multiple medical issues complicated the management and treatment of withdrawal and he required inpatient medical hospital detoxification treatment. He did require 24 hour medical hospital treatment for alcohol detoxification and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He required at least the entire duration of stay, as he was at risk for life threatening and complicated withdrawal including delirium tremens. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

It did not appear that the health care plan decision was reasonable, considering medical evidence, or in the best interests of the patient.

The insurer's denial of coverage for the inpatient hospital is overturned. Medical necessity is substantiated.