Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed.   

This is a male patient who was admitted to the hospital after having a tonic clonic seizure.  He bit his tongue and was noted to be shaking throughout the seizure.  He reported drinking large amounts of alcohol but had stopped three days prior to his presenting to the hospital.  He also endorsed smoking cannabis daily.  He was post-ictal, confused with a headache and was slow to answer questions.  He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 8.  He received Librium and Lorazepam for his withdrawal.  He was discharged home after being deemed medically stable.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as this patient reportedly had a seizure after stopping alcohol use several days prior to admission and reportedly was drinking large amounts of alcohol so the seizure appeared to be due to alcohol withdrawal, which is considered complicated withdrawal and requires inpatient hospital detoxification treatment.  

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.  

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 reports of a seizure which appeared related to alcohol withdrawal.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive setting for detoxification as it reports that patients with withdrawal seizures are in need of inpatient detoxification treatment in a medical hospital as this is considered complicated withdrawal.  This put him more at risk for even more complicated, severe, and life threatening withdrawal such as delirium tremens so he required detoxification in this hospital setting.  He was ordered a Librium detoxification every 8 hours as needed, and he required and received detoxification medication of Lorazepam.  He required and needed detoxification medications to modify withdrawal and prevent even more serious withdrawal.  He was at risk for more severe and life threatening withdrawal symptoms.  He could not safely be treated in a less restrictive setting other than a hospital setting due to this and his risk of more complicated or life threatening withdrawal symptoms including delirium tremens in addition to his likely withdrawal seizure. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.  

The carrier's denial of coverage for the acute inpatient hospital admission is reversed.  The medical necessity is substantiated.