Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain, Suicidal ideation
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned. 

This is a male patient who was admitted for inpatient hospital treatment due to chest pain and suicidal ideation with a plan to jump in front of a train. The patient reported alcohol withdrawal symptoms including nausea, diaphoresis, severe hypertension with a blood pressure of 178/98, recent visual hallucinations, and he had reports of chest pain and dyspnea. The patient reported heavy alcohol use including drinking 4-5 pints of vodka per day and had reports of frequent blackouts. On examination, the patient had a contusion on his forehead. Laboratory findings revealed that the patient had a low magnesium level and elevated liver function test (LFT). The patient's electrocardiogram (EKG) revealed a prolonged QT interval. The patient's toxicology test was positive for benzodiazepines and alcohol. The patient's history was significant for recurrent incarcerations for theft and robberies. The patient's medical history included coronary arty disease, asthma, and hypertension. During the hospital stay, the patient was put on a 1:1 Observation for suicide watch, and was treated with benzodiazepine taper for detoxification. 

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. 

In this case, this patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to his very heavy daily alcohol use, and he reportedly had serious comorbid medical issues complicating the management of withdrawal including chest pain, dyspnea, high blood pressure, a prolonged QT interval, hypomagnesemia, and hypertransaminasemia. The patient also had active alcohol withdrawal symptoms and he also had reports of depressive symptoms including suicidal ideation and plan. Thus, the patient was considered a danger to self and in need of close monitoring and treatment in the hospital. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 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 and required detoxification medication to modify withdrawal from alcohol. The patient required 24-hour medical hospital detoxification treatment and it was considered unsafe for him to have detoxification at a less restrictive level of care. 


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

The medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.