Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intoxication
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is overturned.

The patient is an adult female. She presented to the emergency department with complications of severe alcohol use disorder. She presented with complaint of three days of nausea and vomiting with abdominal pain with onset after stopping use of alcohol. She reported using up to four bottles of tequila per day. There is history of withdrawal seizures and severe withdrawal symptoms. She had past substance-related treatments with detoxification and rehabilitation services with relapse. Evaluation showed increased heart rate, electrolyte abnormalities with low magnesium, and evidence for acute kidney injury with metabolic acidosis. She was malnourished and anemic. Electrocardiogram (EKG) showed sinus tachycardia and a prolonged QT interval. She received supportive measures in the emergency department that included vitamin replacement including thiamine and folate, fluid and electrolyte replacement therapy with intravenous administration, and treatment with Ativan and anti-emetics with Clinical Institute Withdrawal Assessment (CIWA) monitoring. The patient was admitted to inpatient hospital care following the medical screening with plans for appropriate monitoring and detoxification and withdrawal management of severe alcohol use disorder with continued use of supportive measures, vitamin replacement, intravenous fluids, and anti-emetics. On day #2, the patient was feeling better and advanced to a liquid diet with use of pantoprazole and famotidine and Librium. Abdominal X-ray found no abnormality. The Clinical Institute Withdrawal Assessment scores had ranged from eight to 12 despite treatment until day #3 when the Clinical Institute Withdrawal Assessment scale score was zero. The patient was provided education and counseling during the remaining hospital stay. She 
was motivated to make a change with her use of alcohol. Again, vitamins were continued, as well as the availability of comfort medications with monitoring and assistance with daily activities.
The patient was discharged with recommendations for clinically appropriate aftercare. The inpatient stay was denied coverage by the health plan based on medical necessity and plan guidelines with reference to MCG (Milliman Care Guidelines) criteria for inpatient level services. The appeal was based on prevailing standards of care and MCG (Milliman Care Guidelines) and InterQual Criteria for Inpatient Level Care indicating that complex medical judgment and the clinical features of the case warranted inpatient level services for the duration of the inpatient stay including withdrawal management in a patient with history of severe alcohol withdrawal and medical complications of the alcohol use disorder.

The Inpatient admission was medically necessary. 

The presenting clinical features and history and risk for complications of the alcohol disorder including withdrawal seizures and other complications of alcohol use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario. The adult inpatient treatment of this patient's alcohol use disorder and withdrawal did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder. The patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated treatments for general medical comorbidities. Medical necessity for the admission and the continued inpatient services is met in this case and is consistent with prevailing standards of medical practice, published guidelines, and American Society of Addiction Medicine Guidelines and Criteria.