Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned

This patient reportedly was admitted to this inpatient hospital treatment due to severe alcohol withdrawal. The patient reportedly had severe tremors, agitation, confusion and disorientation, moderate to severe visual hallucinations, elevated temperature, and their Clinical Institute Withdrawal Assessment (CIWA) increased on day 2 to 28 which is severe alcohol withdrawal. The patient reportedly had an unreliable history of reporting alcohol use. The patient reportedly had multiple past hospital visits due to alcohol related issues. The patient reportedly also was dehydrated and had a urinary tract infection (UTI). The patient reportedly had blood and bacteria in their urinalysis (UA), had low platelets of 90, elevated aspartate aminotransferase (AST) of 105 and bilirubin of 1.3, and low magnesium and phosphorus of 1.5. The patient reportedly had a urine toxicology positive for alcohol and tetrahydrocannabinol (THC). The patient reportedly was put on a CIWA protocol with Librium and was prescribed 50 milligrams (mg) every 4 hours but also required intravenous (IV) Ativan including 2 mg due to severe alcohol withdrawal. The patient also reportedly had IV fluids, IV antibiotics, magnesium, and potassium, was on continuous telemetry, and received B 12 and folate. The patient reportedly was discharged when medically stable enough. 

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records did provide enough specific evidence to support that the patient required inpatient hospital level of treatment then. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24 hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as the patient continued to have severe withdrawal symptoms and required 2 detoxification medications including IV Lorazepam and Librium. The patient was at medical risk for complicated and life threatening withdrawal such as delirium tremens as the patient's CIWA was very high at 28 with disorientation and confusion so they had mental status changes. The patient had reports of multiple past hospital episodes due to alcohol related issues.  The patient did require 24 hour inpatient medical hospital treatment for alcohol detoxification and it was considered unsafe for them to be treated for detoxification in a less restrictive level of care then. The medical records provided enough specific evidence to support that the patient required inpatient hospital treatment for alcohol detoxification. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission is substantiated.