Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment: Inpatient services

The insurer denied coverage for inpatient services

The denial is overturned

This adult patient was admitted to this inpatient hospital due to alcohol withdrawal symptoms including tremors, nausea and vomiting, tongue fasciculations, elevated heart rate, weakness, and dry mouth. The patient had a seizure history, and it was uncertain if it was related to alcohol withdrawal or epilepsy. The patient was binge drinking for 10-14 days after abstinence for years and was drinking 1 pint of vodka daily. The patient had high anion gap acidosis, acute kidney injury, transaminitis, hyperbilirubinemia, elevated lipase, and liver function tests (LFT's). The patient was given intravenous (IV) Diazepam, IV Pepcid, Librium detoxification protocol, thiamine, folic acid, and Keppra. Addiction medicine and Critical Care were consulted. The acidosis improved, and the patient had no further significant withdrawal symptoms and was discharged. 

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required inpatient hospital 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. 
 
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24 hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting due to continued use of large amounts of alcohol daily including up to 1 pint of vodka per day and active withdrawal symptoms which required detoxification medications (Librium and Diazepam) to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens (DTs). The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at risk for DT's due to the large amount of alcohol use daily with active withdrawal symptoms. The patient also had medical problems including high anion gap acidosis, acute kidney injury, transaminitis, hyperbilirubinemia, elevated lipase and LFT's, and a history of seizure with uncertainty if related to alcohol withdrawal or epilepsy. The patient did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment, and it was considered unsafe for the patient 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 services is substantiated.