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 this hospital on the medical floor for alcohol withdrawal treatment. It was reported that the patient had tremors and had blackouts and visual hallucinations. It was reported that the patient was drinking 1-2 liters of whiskey per day but stopped abruptly 2 days prior to admission and reported that was their longest recent abstinence period. It was reported that the patient had groin pain and wanted to be checked for sexually transmitted diseases (STD's) also. The patient's urinalysis (UA) was positive for bacteria, epithelial cells, and protein. The patient reportedly had  a diagnosis of Alcohol Use Disorder with withdrawal. The patient reportedly drank alone and had no past alcohol detoxification or rehabilitation treatment. The patient reportedly was put on a Librium Clinical Institute Withdrawal Assessment (CIWA) protocol for detoxification treatment. The patient also reportedly received intravenous (IV) fluids, thiamine, and folic acid. The patient reportedly was living with their grandparents. The patient reportedly left against medical advice (AMA) before completing treatment for alcohol detoxification.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that the patient had no hemodynamic, pulmonary, metabolic, or neurological reasons for treatment in an acute hospital setting. They recommended a less restrictive level of care then.

The medical records provided enough specific evidence to support that this patient required this level of care then. 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 been drinking large amounts of alcohol daily including up to 2 liters of whiskey and stopped abruptly 2 days prior to admission which put him at high risk for severe, complicated, and even 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 this. The patient did require 24 hour 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 patient also had tremors and visual hallucinations and was put on a CIWA protocol and prescribed Librium for detoxification treatment to prevent more  severe, complicated, and even life threatening withdrawal. The patient reportedly could not stop alcohol use and reported that due to medical complaints of groin pain they stopped abruptly 2 days prior to admission putting them at high risk medically. 

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 the inpatient admission is substantiated.