Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to inpatient hospital treatment on with vaginal bleeding, alcohol withdrawal including a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 14.  The patient had reports of elevated heart rate of 118 and vomiting, and also had starvation ketoacidosis. The patient reportedly was drinking 1 liter of vodka per day for the past week with the last drink one day prior to admission. The patient reportedly had other medical issues including transaminitis and lactic acidosis, and had a history of anemia and pancreatitis. The patient reportedly had stressors of possible eviction from their residence and court issues including custody issues as the patient's ex-husband had custody of their children. The patient reportedly had depressive and anxiety symptoms. The patient reportedly was put on a CIWA protocol and Ativan was given for alcohol detoxification treatment. The patient reportedly received 1 milligram (mg) of Ativan intravenous (IV) twice and IV Thiamine and Ondansetron and had continuous IV fluids. The patient reportedly trended down with their CIWA and was discharged. The recommendation was for alcohol inpatient rehabilitation treatment, but the patient was not in agreement.
  
The medical records provide enough specific evidence to support that the patient required this level of care then. 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. 

According to the 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 they continued to use large amounts of alcohol daily including up to 1 liter of vodka daily.  The patient also had active withdrawal symptoms including CIWA of 14 and required and received detoxification medication (Lorazepam) IV to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at high risk for DT's due to their large amount of alcohol use daily with active withdrawal symptoms. The patient also had multiple medical problems as well as psychiatric symptoms of depression and anxiety due to multiple significant stressors including loss of custody of their children and pending court issues and possible eviction. 

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 then and also unsafe for the patient to be treated medically outside of a hospital setting due to their medical history and other medical issues. The patient was considered at risk for worsened medical issues and worsened withdrawal including more severe, complicated, or even life-threatening withdrawal due to their heavy daily alcohol use. 

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 hospital is substantiated.