Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This adult patient reportedly was admitted to this inpatient hospital treatment for alcohol detoxification treatment. He reportedly had active alcohol withdrawal symptoms including nausea, vomiting, tremors, sweats, elevated heart rate of 108-201, elevated blood pressure of 153/93, agitation, anxiety, and dry mucous membranes. He reportedly had low sodium, potassium, magnesium, chloride, and his QTc (interval on electrocardiogram (EKG)) was high at 494. He reportedly still had moderate withdrawal with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 16. He reportedly had 2 detoxification medications including Diazepam and Phenobarbital. 
  
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. In this case this patient had been drinking large amounts of alcohol daily for several days in a binge and then experienced alcohol withdrawal including nausea, vomiting, tremors, sweats, elevated heart rate of 108-201, elevated blood pressure of 153/93, agitation, anxiety, and dry mucous membranes and had a CIWA of 16 the next day indicative of moderate withdrawal. He also had medical issues including low sodium, potassium, magnesium, chloride, and his QTc was high at 494.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use and required and needed 2 detoxification medications to modify withdrawal, including Diazepam and Phenobarbital. It was reported that he had 2 doses of intravenous (IV) Diazepam totaling 12.5 mg (milligrams) and 130 mg of IV Phenobarbital and 2 doses of oral phenobarbital for a total of 194.4 mg in the first 24 hours. Notes reported a CIWA of 16 which is moderate withdrawal, and he still had an elevated heart rate of 104 and elevated blood pressure of 148/96 and additional Diazepam of 7.5 mg for detoxification was needed including the IV Phenobarbital every 8 hours. 

He needed 24-hour inpatient hospital 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 such as delirium tremens. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required at least the entire time in this 24-hour inpatient detoxification treatment. 

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 admission is overturned. Medical Necessity is substantiated.