Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol related pancreatitis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

This adult male was admitted to this inpatient hospital for severe sudden onset epigastric pain while drinking alcohol. He had nausea, elevated blood pressure of 152/97, elevated heart rate of 109-119, and symptoms and findings were consistent with alcohol related pancreatitis. He reportedly had multiple past episodes of alcohol related pancreatitis. He had multiple abnormal lab findings including elevated lipase, alanine transaminase (ALT), bilirubin, creatinine, hematocrit, triglycerides, and low platelets, sodium, and chlorine. He also reportedly had past alcohol withdrawal seizures. He was drinking 6 beers and last reported use the night prior to admission. He was given intravenous (IV) Ativan, Ketorolac, Zofran, Benadryl, and IV fluid bolus. His abdominal computed tomography (CT) scan revealed retroperitoneal edema and unorganized fluid compatible with pancreatitis. He also had a history of heroin use and was taking Suboxone. 

The United States (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 multiple comorbid medical conditions due to alcohol use requiring hospital treatment and also had a history of past alcohol withdrawal seizures, so he required hospital treatment for monitoring and management of withdrawal. He had nausea, elevated heart rate, and severe abdominal pain. He was given IV Ativan and IV morphine. He reportedly drank alcohol the night prior to admission. He also had a history of heroin use and was taking Suboxone. Notes reported that he still had severe abdominal pain and was unable to even tolerate Jell-O. He still had elevated heart rate of 98-113. He also still had abnormal labs including increased lipase of 940, creatinine of 1.36, bilirubin of 1.43, lower sodium at 131, and still had a hematocrit of 45 after aggressive IV hydration. Notes reported that he still had significant pain, elevated bilirubin of 2.2 and low platelets at 83. Notes reported that he still had no bowel movements, still had pain 7 out of 10, and took 4 milligrams of IV Morphine in 24 hours. He also had a nutrition consult put in. Notes reported that he had pain 6-7 out of 10, had IV Morphine 5 times in the past 24 hours, and had elevated blood pressure of 152/97.

The patient was considered at risk of alcohol withdrawal, and he had past complicated withdrawal as he had a seizure, so he required hospital treatment for monitoring. His labs worsened days 2-3 and he had multiple days of aggressive IV fluids and IV analgesics in addition to being monitored for alcohol withdrawal. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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