Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed. 


This is a male patient with a history alcohol withdrawal seizure, hypertension, and status post colectomy. He presented to the emergency department (ED) with complaints of tremors and poor sleep. The patient reported drinking multiple alcoholic beverages per day and attempted to decrease his alcohol consumption for the past couple of days and began to develop withdrawal symptoms. The patient's Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 5. Laboratory work up was performed that revealed an elevated lactic acid,  AST of 77, ALT of 47, alkaline phosphatase of 133, magnesium of 1.3, potassium of 3.2, platelets of 148, and a blood urea nitrogen (BUN) of 4. A physical exam was performed that showed angioedema and supraglottis with swelling of his face and throat. The patient was treated with intravenous (IV) fluids, IV Ativan, IV Pepcid, IV antibiotics, dexamethasone, and Diphenhydramine. The patient left the hospital against medical advice (AMA).

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. Also, 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, and also had a past history of alcohol withdrawal seizures that met the clinical criteria for inpatient medical detoxification treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this 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 alcohol daily, required and received intravenous (IV) detoxification medication (Ativan) to modify withdrawal from alcohol and prevent another withdrawal seizure of more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens (DTs) can occur 3-4 days after alcohol use, and this patient was considered at high risk for DTs because he tried to decrease alcohol use for the past couple of days prior to admission and was experiencing active withdrawal symptoms requiring IV detoxification on admission. The patient's past history of withdrawal seizures put this patient at a high risk for DTs at baseline. 

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 admission is reversed.  The medical necessity is substantiated.