Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This adult male reportedly went to the hospital due to alcohol withdrawal symptoms and epigastric pain considered due to gastritis due to alcohol use. He reportedly had a Clinical Institute Withdrawal Assessment (CIWA) score of 18 and had reports of alcohol withdrawal symptoms including multiple episodes of vomiting, nausea, agitation, elevated heart rate of 101, and elevated blood pressure of 162/99. He reportedly was drinking 1 and 12 pints of vodka per day for the past 5 days with last use 7 hours prior to coming to the hospital by emergency medical services (EMS). He reportedly had hypertension and chronic pancreatitis. He had abnormal labs including low Chloride and low Bicarbonate, elevated liver function tests (LFT's), elevated pH, and critically high lactic acid level. He reportedly had 2 past inpatient rehabilitation treatments and past inpatient detoxification treatments due to alcohol use and withdrawal. He was given Lorazepam 2 milligrams (mg) intravenous push (IVP) twice for detoxification treatment and was given Ondansetron 4 mg IVP twice for nausea and vomiting, Famotidine and Pantoprazole IVP once for epigastric pain, and Hydromorphone IVP once for pain. He was given a clear liquid diet and had an infusion of normal saline. He was given thiamine and folic acid and put on seizure precautions. He also reportedly had depression and anxiety. He was recommended to complete inpatient detoxification and then be discharged to inpatient alcohol rehabilitation treatment, however he left against medical advice (AMA) prior to completing the detoxification treatment.

The medical records provided enough specific evidence to support that he 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 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 conditions 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. 

According to the Level of Care Determination (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he required and received detoxification medication including IV Lorazepam to modify withdrawal from alcohol and prevent severe, complicated, or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this.  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. 

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 inpatient hospital admission is substantiated.