Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This patient was admitted to this inpatient hospital treatment due to alcohol withdrawal and the need for alcohol detoxification treatment. He reportedly had nausea and vomiting with streaks of blood, elevated heart rate of 116 on admission which increased to 140, worsened anxiety, abdominal pain, fluttering of his chest, tremors, elevated diastolic blood pressure of 102 and an initial Clinical Institute Withdrawal Assessment for Alcohol (CIWA of 8 which increased to 14 thus indicating acute alcohol withdrawal). He was drinking 2 pints of vodka and cognac per day and was on a 5-day binge. He had elevated liver function tests (LFTs). There was concern for a Mallory Weiss tear due to his alcohol use. He had a recent alcohol withdrawal episode 2 weeks prior to this admission. He had past inpatient alcohol detoxification treatment. He reportedly had an abnormal electrocardiogram (EKG) with persistent tachycardia, first degree atrial-ventricular (AV) block, and nonspecific T wave (interval on an EKG) abnormalities. His abdominal ultrasound revealed an echogenic liver. He reportedly was given Librium and put on a CIWA protocol and prescribed Ativan as needed (prn) for withdrawal also, was on telemetry monitoring, given thiamine and folic acid, famotidine, Zofran, and intravenous (IV) fluids. He continued to receive and require detoxification treatment but left against medical advice (AMA) despite strong recommendations to remain in this hospital setting for continued detoxification treatment.
  
In this case this patient had active alcohol withdrawal symptoms including nausea and vomiting with streaks of blood, elevated heart rate of 116 on admission which increased to 140, worsened anxiety, abdominal pain, fluttering of his chest, tremors, elevated diastolic blood pressure of 102 and an initial CIWA of 8 which increased to 14 thus indicating acute alcohol withdrawal. He also had comorbid medical conditions complicating the management of withdrawal including elevated LFT's, elevated heart rate and diastolic blood pressure,  abnormal EKG with persistent tachycardia, first degree AV (Atrioventricular) block, and nonspecific T wave abnormalities and his abdominal ultrasound revealed an echogenic liver, and there was concern for a Mallory Weiss tear due to his alcohol use and vomiting with streaks of blood. He was considered to be at risk medically due to his worsening alcohol withdrawal and multiple medical issues.

According to the Level of Care for Alcohol and Drug Treatment (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 including up to 2 pints of vodka and cognac per day, needed detoxification medication (Librium standing and Ativan prn) to modify withdrawal from alcohol. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at risk for this. He reportedly had multiple past alcohol withdrawal episodes and past inpatient alcohol detoxification treatment and still could not maintain abstinence so he likely would not have been able to maintain abstinence without being in a 24-hour inpatient hospital setting. He left AMA prior to completing the detoxification but still required inpatient detoxification treatment.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital admission is substantiated.