Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.

Treatment: Inpatient admission.

The plan denied inpatient admission.

The denial is overturned.  	

This adult male was admitted to the hospital after being brought to the emergency department (ED) by emergency medical services (EMS). He reportedly was found lying outside and was confused to time. He had alcohol withdrawal symptoms including tremors, nausea, diaphoresis, agitation, elevated heart rate of 111, and had a temperature as high as 103. He reportedly drank 4 bottles of vodka and many beers. He had multiple past ED visits for similar complaints. He had hypertension, alcoholic hepatitis, and depression. He was given Lorazepam intravenous (IV) and oral (PO) for withdrawal and put on a Librium taper and Clinical Institute Withdrawal Assessment of Alcohol (CIWA) protocol. He also was given IV thiamine, folic acid, and fluids. He was given antibiotics. He reportedly signed out against medical advice (AMA) despite recommendations to continue and complete his 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. Also, the United States (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 active alcohol withdrawal symptoms including tremors, nausea, diaphoresis, agitation, elevated heart rate of 111, and had a temperature as high as 103, and a CIWA ranging up to 17 and was at risk of more severe, complicated, and life-threatening withdrawal symptoms and thus required inpatient detoxification treatment in this hospital setting. 

According to the Level of Care for Alcohol & Drug Treatment Referral (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 continued to use large amounts of alcohol including drinking 4 bottles of vodka and many beers and active alcohol withdrawal symptoms, and he required and received detoxification medications (Lorazepam and Librium) to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens (DT's). The risk of DT's can occur 3-4 days after alcohol use so he was considered at high risk for DT's due to his large amount of alcohol use daily with active withdrawal symptoms. He was on a CIWA protocol with a Librium taper and Ativan as needed as he had Ativan 1 milligram (mg) IV times 2 and 3 mg of Ativan PO in addition to the Librium taper. He did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment. 

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 inpatient admission is substantiated.