Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute coronary syndrome (ACS) and alcohol intoxication/withdrawal.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient who was admitted for inpatient hospital treatment. The patient reported chest pain, diaphoresis, and shortness of breath after walking 2-3 blocks, and was admitted with acute coronary syndrome (ACS) and alcohol intoxication/withdrawal. The patient reportedly had nausea, 2-3 vomiting episodes, and nervousness and was put on an Ativan protocol for detoxification. The patient was living in an alcohol rehabilitation program for 8 months and relapsed with alcohol use shortly after discharge. The patient had multiple medical issues including chest pain, diaphoresis, and shortness of breath, abdominal tenderness, vomiting, and atrial fibrillation as well as hypertension. The patient was treated with Ativan, intravenous (IV) fluids, as well as other cardiac medications. The patient was stabilized and was then discharged.
  
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. 

In this case, this patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to alcohol use, and he reportedly had comorbid medical issues complicating the management of his alcohol withdrawal. The patient reported chest pain, diaphoresis, and shortness of breath after walking 2 -3 blocks and was admitted for rule out ACS and treatment for alcohol intoxication/withdrawal. The patient had nausea, 2-3 vomiting episodes, and nervousness, atrial fibrillation as well as hypertension. The patient was considered a medical risk and due to his multiple, active medical issues, the patient was considered in need of 24-hour hospital treatment for detoxification; the patient was treated on Ativan protocol. The patient's blood alcohol level (BAL) on admission was 164 and he last reported drinking alcohol the morning of this hospital admission. The patient relapsed shortly after completing his 8 month alcohol rehabilitation program. This indicated that this patient was unstable and unable to maintain abstinence outside of an inpatient, 24-hour monitoring setting and detoxification treatment. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically and requiring 24-hour hospital treatment. 

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. 

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 hospital admission should be overturned. The medical necessity is substantiated.