Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol abuse, Diabetic ketoacidosis. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient with a past medical history of diabetes mellitus (DM) type 2 and alcohol abuse who was admitted to the hospital due to alcohol withdrawal symptoms and diabetic ketoacidosis. The patient had alcohol withdrawal symptoms including nausea, vomiting, fever, body aches, and tremors. The patient had diabetes and had diabetic ketoacidosis. The patient reportedly was drinking heavily on weekends. The patient reported depressed mood and concerns about finances. The patient was put on a Librium Taper, as well as ondansetron, intravenous (IV) fluids, a banana bag, IV insulin, folic acid, and thiamine. The patient completed the detoxification protocol and also agreed to take naltrexone to help decrease his cravings for use and was discharged on day 4 of admission. 

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. Also, the United States (US) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (DHHS-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 comorbid medical conditions complicating the management of withdrawal including diabetic ketoacidosis with current alcohol withdrawal symptoms including nausea, vomiting, fever, body aches, and tremors. The patient was thus at high risk of more severe, complicated, or life-threatening withdrawal or worsened medical issues and he required 24-hour hospital treatment as a result. Notes on day 3 of admission stated that the patient continued with the clinical Institute Withdrawal Assessment for Alcohol (CIWA)-Librium protocol. Notes on day 4 of admission reported that the patient completed the detoxification protocol and also agreed to naltrexone treatment to help target cravings for alcohol. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol on weekends, had detoxification medication ordered to modify withdrawal from alcohol and prevent more severe, complicated, or life-threatening withdrawal. The patient required 24-hour medical hospital treatment for alcohol withdrawal detoxification treatment and treatment of his concurrent diabetic ketoacidosis so it was considered unsafe for the patient to be treated in a less restrictive level of care then. 

The health plan did not act reasonably with sound judgment and in the best interests of the patient. 

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.