Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned. 

This male patient has a history of alcohol abuse, polysubstance abuse (cocaine, synthetic cannabinoid, marijuana, heroin), gastroesophageal reflux disease (GERD), left inguinal hernia, schizophrenia, post-traumatic stress disorder, and bipolar disorder. The patient presented to the Emergency Department (ED) for chest pain and left ankle pain after blacking out and falling while using synthetic cannabinoid. The patient also reportedly smoked crack and drank a few hours prior to falling. The patient's vital signs in the ED were blood pressure 128/81, heart rate 86, temperature 37.3 degrees Celsius, respiratory rate 23, and oxygen saturation 99% on room air. The patient was found to have acute kidney injury (AKI). The patient was admitted to inpatient care, Geriatrics, for alcohol withdrawal. During the hospital course, the patient was treated with Librium. The patient was evaluated by Psychiatry and the recommendation was to hold psychotropic medications due to the patient's withdrawal status. Psychotropic medications were re-started after the patient was determined to be stable. 
	
The APA (American Psychiatric Association) 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 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 alcohol use, and also was at risk medically due to his crack and K2 (a kind of synthetic cannabinoid) use along with his alcohol use. He reportedly had active medical issues in addition to active alcohol withdrawal symptoms putting him more at risk medically. According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral), he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use alcohol, crack/cocaine, and K2 synthetic cannabis despite medical issues and comorbid psychiatric conditions. He also reportedly lacked supports and was homeless, so it was not likely that he could be compliant with outpatient treatment. He was non-compliant with medications and follow up appointments. Also, the records did support that he was at risk medically as he was experiencing active alcohol withdrawal symptoms and had active medical issues including acute renal injury and dehydration, and he required and received detoxification medication (Librium) to modify withdrawal and prevent more severe and possible life threatening withdrawal symptoms. This was evidence that he needed 24 hour hospital treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour hospital setting, including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues.

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 is overturned. The medical necessity is substantiated.