Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This male was admitted to the hospital due to liver cirrhosis secondary to alcohol liver disease and evaluation of abdominal hernias. He had new onset ascites secondary to alcohol use and lower extremity swelling as well as hepatomegaly. He had a model for end stage liver disease (MELD) score of 18 which indicated 3-4% (percent) mortality in 90 days. He had significant alcohol abuse, drinking up to 10 beers per day for many years. He reportedly needed to drink every morning due to alcohol withdrawal symptoms including tremors and anxiety. He reportedly had past alcohol inpatient rehabilitation treatment and was abstinent 6 years, but relapsed. He reportedly was put on a CIWA (Clinical institute for Alcohol Withdrawal) protocol with Ativan, given thiamine and MVI (multivitamin concentrate [intravenous infusion]), and 2 bags of KCl (potassium chloride). He reportedly had a paracentesis for ascites and had surgery and GI (gastroenterology) consults. He was transferred to the liver center with a hepatologist for continued inpatient treatment. 
  
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 significant medical issues due to his long-term heavy alcohol use including liver cirrhosis and hepatomegaly and new onset ascites, as well as the need for a CIWA protocol to monitor withdrawal as he had to drink each morning due to alcohol withdrawal including tremors and anxiety to decrease withdrawal and prevent more severe withdrawal including complicated and life-threatening withdrawal such as DT's (delirium tremens). The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this especially with his heavy daily alcohol use and significant medical issues including severe liver disease with new onset ascites. He did require 24-hour medical hospital treatment for monitoring of alcohol withdrawal with CIWA protocol for detoxification and also his significant medical issues complicating the management of withdrawal, so it was considered unsafe for him to be treated in a less restrictive level of care other than a medical hospital. He was transferred from this hospital to a liver center for further treatment with a hepatologist, so he required this medical hospital treatment. As a result, the recommendation is to overturn 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.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.