Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Hospital admission
The insurer denied coverage for hospital admission.
The denial is overturned.

This adult was admitted to the inpatient hospital due to an alcohol withdrawal seizure, syncope, dizziness, and tremors. She reportedly was drinking 1 bottle of tequila per day. She had a positive toxicology for opiates, benzodiazepines, and tetrahydrocannabinol (THC) and was reportedly using Xanax.  She reportedly stopped substance and alcohol use hours prior to the seizure. She reportedly also had a diagnosis of post-traumatic stress disorder (PTSD) after her boyfriend died in a motor vehicle accident and had diagnoses of Generalized Anxiety Disorder and Alcohol Use Disorder. She was Coronavirus (COVID) positive. The patient was placed on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and prescribed Librium, had telemetry monitoring, and was on seizure precautions. She had neurology and psychiatry consultation prior to discharge. 
 
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that she required this 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

In this case the patient had reports of an alcohol withdrawal seizure requiring inpatient medical hospital detoxification treatment. She was considered at risk for even more severe withdrawal, or complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at high risk for severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment. Her toxicology was positive for Xanax, opiates and THC, so she was also at risk of overdose. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol daily and required and received detoxification medication including Librium to prevent another withdrawal seizure or more severe or life-threatening withdrawal, such as delirium tremens. She also had COVID. She did require 24-hour inpatient medical hospital treatment for alcohol detoxification, and it was considered unsafe for her to be treated for detoxification in a less restrictive level of care then. She was considered a high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment and had comorbid psychiatric issues contributing to her alcohol and substance use.  

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.