Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol withdrawal.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
This is an adult with a history of hypertension, diverticulitis, prodromal episodes of seizures and past alcohol withdrawal seizures. The patient was admitted to this inpatient hospital due to alcohol withdrawal symptoms, gastritis and abdominal pain. The patient reported drinking 1 liter of vodka per day. The patient was noted to have tremors, nausea, anxiety, elevated blood pressure of 174/119. The patient was placed on the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol after receiving Ativan intravenous (IV) for detoxification treatment. The patient continued to have alcohol withdrawal symptoms and was given Ativan for detoxification, but the patient left against medical advice (AMA) despite the recommendation for inpatient alcohol rehabilitation treatment after completion of this detoxification treatment. 

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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

The 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 patient's ability to attend daily outpatient treatment is a problem, if one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. 

In this case, the patient had a history of past withdrawal seizure and had current active alcohol withdrawal symptoms including tremors, nausea, anxiety, elevated blood pressure of 174/119, and had multiple acute and active medical issues including severe hypertension and diverticulitis. The patient continued to have withdrawal symptoms with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 6, was still on an Ativan taper for detoxification treatment, had received intravenous hydration, Protonix, morphine for pain, thiamine and folic acid. He required serial vital signs monitoring. The patient also had low platelets, elevated alkaline phosphatase (AP) and elevated aspartate aminotransferase (AST). Notes on day 2 of admission reported that the patient still had withdrawal, including a CIWA of 3 and was still on an Ativan taper for detoxification treatment.

The standard treatment when one has a history of alcohol withdrawal seizure is for inpatient hospital detoxification. The patient was considered at high risk medically for severe, complicated, and life-threatening withdrawal, especially due to a past alcohol withdrawal seizure and current prodromal episodes of seizure. The risk of life-threatening withdrawal, such as delirium tremens, increases 3-4 days after alcohol use; therefore, the inpatient hospital admission was medically necessary. 

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 hospital admission is substantiated.