Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol withdrawal.
Treatment:  Inpatient hospital stay.

The insurer denied coverage for an inpatient hospital stay.  The denial is overturned. 

This is a male patient, who was admitted to the hospital for detoxification from alcohol.  On hospital presentation, the patient had clinical signs and symptoms of withdrawal including nausea, vomiting, increased heart rate, increased blood pressure, and slightly elevated temperature.  The patient reported drinking 1 pint of alcohol per day, daily up to 3 days prior to hospital arrival.  The patient reported multiple past inpatient detoxification treatments in the past.  The patient reportedly also had low platelets.  The patient was admitted and was started on the Ativan protocol for alcohol detoxification.  The patient then left against medical advice (AMA).

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.  Also, the 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 active withdrawal symptoms and was at risk for more severe, complicated, and life threatening withdrawal due to his large amount of daily alcohol use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment, as he could not have been safely and effectively treated for detoxification in a less restrictive setting, as he continued to use alcohol daily despite multiple past inpatient detoxification treatments.  The patient required and received detoxification medication (i.e. Ativan) to modify his withdrawal from alcohol and prevent more severe, complicated, or life threatening withdrawal such as delirium tremens.  The risk of delirium tremens can occur 4 days after alcohol use, so the patient was considered at risk for this complication. 

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.