Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is overturned.

This patient was brought in by emergency medical services (EMS) after being found confused and vomiting on a ferry. It was reported that he was nauseous and confabulating also. He reportedly drank 3 pints of vodka, and there was concern for Wernicke's encephalopathy. The neurology consult was questioning whether the altered mental status was the result of a seizure due to alcohol withdrawal. The patient had multiple medical issues including elevated liver enzymes. There was concern for liver failure as well. He had reports of worsened cirrhosis and varices secondary to portal hypertension and acute hepatitis. He reportedly had acidosis with an anion gap of 21.9. He reportedly also had ketones in the urine. He also had pancytopenia and dehydration. He reportedly was put on a CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol of Ativan 2 mg (milligrams) q (every) 6 hours prn (as needed) and seizure precautions. He reportedly was given IV (intravenous) fluids, folic acid, and thiamine. He also had diabetes and hypertension. He reportedly was discharged.
  
Also, the US (United States) 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 several comorbid medical conditions complicating the management of withdrawal and he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment.  

According to the LOCADTR (Level of Care Determination) 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 a large amount of alcohol including 3 pints of vodka the day prior to admission, and he had active withdrawal symptoms including nausea and vomiting and a possible withdrawal seizure as per neurology consultation with altered mental status with confusion and confabulation. He reportedly had multiple medical issues including elevated liver enzymes, and there was concern for liver failure, and he had reports of worsened cirrhosis and varices secondary to portal hypertension and acute hepatitis as well as acidosis with an anion gap of 21.9, ketones in the urine, pancytopenia and dehydration. The risk of delirium tremens (DT) can occur 3-4 days after alcohol use, so he was considered at risk for DT's, and there was concern for Wernicke's encephalopathy due to his confusion and altered mental status, so he required 24-hour hospital treatment. He reportedly could not function and could not care for basic needs as well. He did require 24-hour medical hospital treatment for alcohol detoxification and monitoring and treatment of multiple medical issues. It was considered unsafe for him to be treated in a less restrictive level of care then and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues requiring hospital treatment then as well as the need for detoxification monitoring and CIWA treatment protocol in the hospital setting.

Inpatient hospital treatment was medically necessary. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.