Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

This young adult was admitted to this inpatient hospital due to alcohol withdrawal. He had moderate alcohol withdrawal as he had tremors, was shaking and there was a question as to if this were an alcohol withdrawal seizure. It was also noted that he had sweats, increased heart rate of 107, elevated blood pressure of 134/96, nausea and vomiting, tongue fasciculations, dizziness, and he had a clinical institute withdrawal assessment (CIWA) score of 12 which increased to 19. He reportedly was drinking large amounts of alcohol daily including 3-4 bottles of vodka per day with a 4-year history. He had been in a past alcohol rehabilitation and relapsed immediately after that. He was given IV (intravenous) Diazepam without reported improvement initially, so he was admitted to this hospital for treatment. He was given Librium for detoxification treatment, intravenous fluids, IV Zofran and Famotidine, thiamine, folic acid, multivitamin (MVI), IV magnesium (Mg) due to low Mg, and had serial lab monitoring and urine drug screening.
  
The medical records provided enough specific evidence to support that he required inpatient 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 current or 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 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 moderate alcohol withdrawal and had tremors, was shaking and there was a question as to if this were an alcohol withdrawal seizure, sweats, increased heart rate of 107, elevated blood pressure of 134/96, nausea and vomiting, tongue fasciculations, dizziness, and he had a CIWA of 12 which increased to 19. He reportedly was drinking large amounts of alcohol daily including 3-4 bottles of vodka per day with a 4-year history which put him a high risk for severe, complicated, and life-threatening withdrawal including delirium tremens. There was concern that his shaking was due to an alcohol withdrawal seizure also. His CIWA went from 12 to 19 and he was getting worse in terms of withdrawal. He also reportedly had comorbid active acute medical issues including low magnesium and required IV Mg supplementation. He also reportedly had transaminitis. He also reportedly was given IV Diazepam without reported and was given Librium for detoxification treatment, IV fluids, IV Zofran and Famotidine, thiamine, folic acid, MVI, IV Mg due to low Mg, and had serial lab monitoring and urine drug screening.

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 full hospital admission is substantiated.