Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleeding

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. The denial is reversed. 

This was then a male who was admitted to the hospital due to abdominal pain and rectal bleeding, as well as diarrhea.  The patient's history was significant for substance (cocaine and heroin) and alcohol use disorders. The patient reported that his daily alcohol use included binge drinking several pints of vodka per day for several days after a several months period of abstinence. The patient reported receiving outpatient substance treatment in the past. The patient's alcohol history was also significant for withdrawal seizure from alcohol. In the ED, the patient's alcohol level was elevated at 176.5. The patient was admitted and was on a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) detoxification protocol with Lorazepam. The patient was also treated with intravenous (IV) banana bag, and buspirone. The patient was discharged.

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 co-morbid 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. In this case, this patient had comorbid medical conditions complicating the management of withdrawal. In the setting of having high alcohol level in the blood, the patient had esophagitis and duodenitis and was admitted for gastrointestinal bleeding. The patient's alcohol history was concerning as this patient relapsed after abstinence and was reporting binge drinking. Given this patient's history of seizure with alcohol withdrawal, this patient was at high risk for life-threatening withdrawal, such as delirium tremens. 

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 the patient was using large volume of alcohol daily as well as heroin and cocaine. Based on the review of the literature and the medical record, the patient required inpatient detoxification with Lorazepam. Thus, the inpatient admission was medically necessary to safely treat this patient's alcohol withdrawal and prevent life-threatening withdrawal associated with this patient's heavy alcohol use and substance use, and also complicated by this patient's comorbid medical condition (GI bleed). 

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 should be reversed.  The medical necessity is substantiated.