Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol dependence.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned.

This is a male patient with a medical history of alcohol dependence who was admitted for inpatient hospital treatment due to alcohol withdrawal symptoms and the need for detoxification treatment.  The patient's past medical history was significant for pancreatic cancer, chronic obstructive pulmonary disease (COPD), and traumatic brain injury (TBI).  The patient reported drinking 1 pint of liquor with last use one day prior to admission.  The patient was admitted and treated with intravenous (IV) Ativan, thiamine, and folate, and he was put on a Librium protocol.  However, before completing treatment, the patient left the hospital against medical advice (AMA) the day after being admitted. 

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 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 presented with a withdrawal seizure due to alcohol withdrawal, as well as other active withdrawal symptoms including, nausea, vomiting, tachycardia, abdominal pain and cramps.  The patient was considered at high risk for life-threatening withdrawal, such as delirium tremens.  The patient's withdrawal was also complicated by comorbid medical conditions including active gastrointestinal bleeding.  The patient reported rectal bleeding and hematemesis, and had a positive guaiac test.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment, as he could not have safely and effectively been treated for detoxification in a less restrictive setting, as he continued to use large amounts of alcohol despite his medical conditions, and required IV detoxification medication (Ativan) and Librium to modify his active withdrawal symptoms even in the setting of high alcohol blood level.  The risk of delirium tremens can occur 3-4 days after alcohol use, and this patient's history and clinical presentation put him at high risk for delirium tremens.  Thus, it is considered unsafe for the patient to be treated for detoxification in a less restrictive level of care. 

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.