Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a male patient who was admitted to this inpatient medical hospital on due to alcohol withdrawal symptoms including a witnessed withdrawal seizure and disorientation. The patient had nausea and vomiting for 2 days prior to admission, tremors, and severe abdominal pain 10 out of 10. He reportedly had multiple past recent hospitalizations for alcohol related pancreatitis and withdrawal. He had elevated liver function tests (LFT's) consistent with alcohol hepatitis. The patient also had hypertension and asthma. He reportedly was drinking alcohol, using methamphetamine, and cocaine. The patient was given intravenous (IV) Ativan for detoxification, IV fluids, Morphine for pain, Benadryl, and magnesium. He improved and was discharged when medically stable.
  
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 current or 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. 

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 complicated severe withdrawal as he had an alcohol withdrawal seizure and required 24-hour medical detoxification treatment in the hospital as a result. He was at risk of even more severe and life-threatening withdrawal including delirium tremens as a result. He had active withdrawal symptoms including withdrawal seizure and disorientation as well as nausea and vomiting for 2 days prior to admission, tremors, and severe abdominal pain, and he reportedly had comorbid medical issues related to alcohol use including alcohol related pancreatitis, elevated LFT's consistent with alcohol hepatitis, and hypertension as well as asthma.  

He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care. He required at least the entire days as it was reported that he had Ativan detoxification. He also was at risk for overdose due to his alcohol, methamphetamine, and cocaine use. This was a high-risk patient who had a withdrawal seizure which requires medical hospital detoxification treatment. 

Inpatient hospital treatment was medically necessary as the chart notes provided enough specific evidence to support that he required this level of care. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical necessity is substantiated.