Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Use and Alcohol Withdrawal

Treatment: continued hospital admission

The insurer is denied coverage for continued hospital admission

The denial is overturned. 

This patient was admitted to this inpatient hospital due to multiple medical problems related to alcohol use and alcohol withdrawal. It was reported that he had high Clinical Institute Withdrawal Assessment (CIWA) and a past history of delirium tremens (DT's). It was reported that he had Ativan for detoxification initially as well as marked electrolyte imbalance due to malnutrition from alcohol use, thrombocytopenia due to alcohol use, and severe depletion of Mg [magnesium], and K [potassium], and required supplementation. He reportedly had racing heart and palpitations and bloody stools, as well as neuropathic pain due to alcohol use. He reportedly had nephrology, gastroenterology, and psychiatry consultations. It was reported that the psychiatry consultant stated that the patient did not have the capacity to make decisions due to alcohol dementia and was considered not only a high risk for relapse, but also unsafe and unable to care for his basic needs. He reportedly was drinking 1 bottle of wine daily. He reportedly was living alone and unemployed. He reportedly continued to have medical issues and was accepted to a rehab and discharged later.
  
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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. This patient could not safely be treated in a less restrictive setting as he reportedly had multiple medical issues related to alcohol use including marked electrolyte imbalance due to malnutrition from alcohol use, thrombocytopenia due to alcohol use, and severe depletion of Mg, and K and required supplementation, and also had racing heart and palpitations and bloody stools, as well as neuropathic pain due to alcohol use, and a history of DT's. This was a very high risk medical patient who required hospital treatment. He also required detoxification with Ativan in the hospital during part of the denial period due to high CIWA scores and a history of DT's which requires inpatient hospital treatment, as this is considered life threatening withdrawal and requires inpatient hospital treatment. It was reported that he no longer was on a CIWA protocol but still complained of neuropathy. 

Notes reported that the psychiatry consultant reported that he did not have the capacity to make decisions and he could not care for his basic needs as he reportedly had alcohol induced dementia and was considered a safety concern if not in this 24-hour hospital until discharged to a 24 hour inpatient rehabilitation setting. He also reportedly was considered high risk for relapse if not in a 24-hour setting and was then at risk for life threatening withdrawal again including DT's, which he reportedly had a history of, and was at risk for worsened medical issues due to alcohol use as he had multiple serious medical issues during this hospital stay due to alcohol use. He was considered a very high-risk patient in need of the entire 24 hour hospital stay. 
Continued inpatient hospital treatment from was medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

Based on the above, the medical necessity for the continued hospital is substantiated. The insurer's denial is overturned.