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 was admitted to the inpatient hospital due to alcohol withdrawal symptoms. He reportedly had bilateral hand tremors and an elevated heart rate of 111. He reported heavy alcohol use with beer and whiskey and then reported that he had not drank in 4 days and started having withdrawal symptoms. His medical history was significant for hypertension and prostate cancer. He had abnormal labs including elevated Aspartate aminotransferase (AST) and alanine transaminase (ALT) and total bilirubin, low potassium of 3.3, elevated lactic acid of 2.6, high CO2 (carbon dioxide) of 37, and an elevated pH (potential for hydrogen) of 7.45. He reportedly fell 4 days prior when drinking alcohol and had abrasions to his left elbow. He reportedly was started on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and was given 2 milligrams (mg) of Ativan and then started on Librium 10 mg 3 times per day for detoxification treatment. He reportedly was also given thiamine, folic acid, intravenous (IV) fluids, Gabapentin for seizure precautions due to alcohol withdrawal, had cardiac monitoring, took Losartan for hypertension, and Lovenox. He reportedly still had withdrawal symptoms of tremors but left against medical advice (AMA) despite recommendations to stay in the hospital for alcohol detoxification treatment.
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required this level of care. 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. In this case this patient had active alcohol withdrawal symptoms bilateral hand tremors and elevated heart rate of 111 and had abnormal labs.

According to the  Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he had a reported history of heavy alcohol use of whiskey and beer 4 days prior to admission and had active withdrawal symptoms putting him at risk for severe, complicated, and life threatening withdrawal, and also required and received 2 detoxification medications (Ativan and Librium) to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. 

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 the inpatient admission is substantiated.