Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol use; alcohol withdrawal 

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial is reversed. 

This patient is a male who was admitted to this inpatient hospital as he was falling due to alcohol use and was being treated for alcohol withdrawal. He reportedly had multiple medical conditions including elevated heart rate, hypertension, CHF, and atrial fibrillation. He fell 3 times prior to admission and had to have the ambulance bring him to the emergency room (ER). He also reported decreased appetite. There was reported suspicion of cardiomegaly. He had premature ventricular contractions (pvc) on the EKG. He was placed on a Lorazepam protocol for alcohol detoxification.  He was reportedly drinking 2 pints of vodka per day. He was discharged and reported that he wanted to attend an alcohol rehabilitation treatment.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the as the chart notes provided enough specific evidence to support that he required 24 hour hospital treatment for alcohol detoxification then. 

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 including up to 2 pints of vodka per day and was falling and hurting himself as a result of alcohol use. He had multiple comorbid medical issues as well including elevated heart rate, hypertension, CHF, and atrial fibrillation, and there was suspicion of cardiomegaly due to alcohol use and dehydration in addition to the multiple recent falls prior to admission. He had nausea and was placed on a Lorazepam protocol for detoxification and also given thiamine, folate, and IV fluids. 
According to the LOCADTR he did require 24 hour treatment as he required 24 hour hospital detoxification treatment as he was considered too at risk for severe, complicated, and life threatening withdrawal such as delirium tremens due to his large amount of alcohol use. Also, he was at risk to hurt himself due to multiple falls as a result of his alcohol use. He could not safely and effectively be treated in a less restrictive setting other than hospital detoxification as he continued to use increased amounts of alcohol despite medical issues and recent falls putting himself at risk of harm.

Inpatient hospital treatment for alcohol detoxification 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 inpatient hospital services is substantiated.  The insurer's denial is reversed.