Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned. 

This is a male patient who was admitted to the hospital for alcohol detoxification, as he had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis.  He reportedly was requesting detoxification from alcohol and cocaine.  He reportedly was drinking 1/2 bottle of whiskey and 5-6 beers daily as well as cocaine daily and cannabis daily.  He reportedly occasionally used ecstasy.  His chest x-ray reportedly revealed pleural effusion, left basilar lung infiltrate, and atelectasis.  He reportedly was put on a Librium taper and also had intravenous (IV) Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.  

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 co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  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 daily alcohol use, and also was using cocaine daily, and he reportedly had  co-morbid medical issues complicating the management of withdrawal.  He reportedly had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis, pleural effusion, left basilar lung infiltrate, and atelectasis and had a history of pulmonary embolism and deep vein thrombosis.  He was considered a medical risk and due to his multiple medical issues and he had reports of active alcohol moderate withdrawal symptoms including tremors, nausea, headache, and sensitivity to light.  He was put on a Librium taper and also had IV Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids. 

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 large amounts of  alcohol and cocaine daily despite medical issues and he required and needed detoxification medication to modify withdrawal including a Librium taper and needed 24-hour treatment then 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 and required 24-hour hospital treatment. 

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

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