Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient hospitalization

The insurer denied coverage for inpatient hospitalization.

The denial is overturned.

This patient was admitted due to chest pain and alcohol withdrawal symptoms. He had a HEART (history, electrocardiogram, age, risk factors, troponin) score of 5 and had chest pain, shortness of breath, blurry vision, and headache. There was a rule out for acute coronary artery syndrome. He also had a medical history for coronary artery disease, myocardial infarction, and hypertension. He had alcohol withdrawal symptoms including tremors, sweats, anxiety, and headache with a Clinical Institute Withdrawal Assessment  (CIWA) as high as 12. He was drinking 1 pint of vodka and 2 packs of beer most days. He reported that he felt as if he were going to have a seizure. He had a positive toxicology for cocaine, benzodiazepine, and opiates. He had prior detoxification inpatient admission. He was put on a Librium protocol and continued to have withdrawal and require Librium detoxification medication while reporting chest pain. He also made a suicidal threat while in the hospital as he stated that there will not be a safe discharge as he will shoot himself and he wanted to get his gun. He reportedly left against medical advice (AMA).
 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with 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. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to large amounts of alcohol use in addition to cocaine use as well as reports of opiate and benzodiazepine use, and he had multiple medical issues complicating the management of withdrawal and putting him at risk medically including rule out for acute coronary artery syndrome. He also was considered at risk for overdose due to large amounts of alcohol and cocaine use as well as opiate and benzodiazepine use as per toxicology reports. Notes reported that he was put on 1:1 (one to one) observation due to a suicidal threat as he reported that there will not be a safe discharge as he would shoot himself and he wanted to get his gun.  His nuclear stress test was canceled due to a positive cocaine toxicology and that he also had crushing pain. 

Notes reported alcohol withdrawal symptoms still including tremors, anxiety, sweats, and headache with a CIWA as high as 12 so he still required alcohol detoxification treatment. Documentation shows that he had tremors and asked for Ativan. He reportedly left AMA. He needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically as well including chest pain. He was using large amounts of serious substances of use and alcohol also putting him at risk medically for overdose and life-threatening withdrawal. He was considered a high-risk patient medically and in need of 24 hour inpatient hospital treatment. 

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.

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