Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Hospital Stay

The insurer denied coverage for inpatient hospital stay.

The denial is overturned.

This patient was admitted due to multiple medical issues. He reportedly was drinking beer daily and had suspected alcohol gastritis, epigastric pain, diaphoresis, tremors, nausea, vomiting, anxiety, elevated blood pressure as high as 177/92, and new onset chest pain. He reportedly had transaminitis, sinus tachycardia, fatty infiltrate of the liver with distended gallbladder, and there was concern for acute coronary syndrome. He reportedly had a hospitalization for gastrointestinal (GI) bleed. He reportedly was given intravenous (IV) Lorazepam twice and put on a CIWA (Clinical Institute of Withdrawal Assessment) protocol and being monitored for alcohol withdrawal with Lorazepam prn (as needed), given IV thiamine/folic acid, IV hydration, had serial cardiac enzymes, IV antiemetics, and antacids. He reportedly was discharged.
  
The American psychiatric Association 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. 

The US (United States) 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 several comorbid medical conditions complicating the management of withdrawal and he had reports of tremors, diaphoresis, nausea and vomiting, and anxiety which required CIWA protocol, and he received 2 IV 1 mg (milligrams) Lorazepam doses. He reportedly was drinking beer daily and was a chronic alcohol user. The risk of delirium tremens can occur 3-4 days after alcohol use and he reportedly was daily for years. He reportedly was at risk for severe, complicated, and life-threatening withdrawal due to daily and long-term alcohol use and he had multiple comorbid conditions with suspected alcohol gastritis so he required inpatient hospital treatment. He was being monitored for alcohol withdrawal. He reportedly had transaminitis, sinus tachycardia, fatty infiltrate of the liver with distended gallbladder, and there was concern for acute coronary syndrome, so he had serial cardiac enzymes also. He was put on a CIWA protocol including IV Lorazepam prn with 2 doses of 1 mg IV Lorazepam, and had IV hydration, and IV thiamine/folic acid, had serial cardiac enzymes, IV antiemetics, and antacids. He reportedly was discharged when he was considered medical stable for discharge. He did require 24-hour medical hospital treatment for alcohol detoxification treatment and medical treatment, and it was considered unsafe for him to be treated in a less restrictive level of care then and also unsafe for him to be treated medically outside of a hospital setting due to his medical issues and alcohol treatment issues needed which required hospital treatment. He was considered at risk for more severe withdrawal and worsened medical issues if not treated in this hospital setting.  

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

The insurer's denial of coverage for the inpatient stays is overturned. Medical necessity is substantiated.