Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.	
The insurer denied coverage for inpatient admission. 
 The denial is overturned.

This patient was admitted to this inpatient hospital treatment due to alcohol withdrawal symptoms including tremors, diaphoresis, intractable vomiting with blood, agitation, sleeping problems, headache, anxiety, and he had a CIWA (Clinical Institute Withdrawal Assessment) score of 12. He reportedly also had a past withdrawal seizure. He reportedly also had abdominal discomfort and increased acid reflux. He reportedly also had an acute kidney injury with an elevated creatinine of 1.37. He reportedly had 2 past inpatient detoxifications with subsequent relapses. He reportedly was given 6 mg (milligrams) of Ativan for detoxification treatment and thiamine, folate, Protonix, and IV (intravenous) hydration. He reportedly had a low sodium of 134, an elevated AST (aspartate aminotransferase) of 55, and elevated CK (creatinine kinase) of 598.7. 
    
This reviewer disagrees with the deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required this intensive level of care 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. It also states that patients with current or 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 US 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 a history of complicated severe withdrawal as he had an alcohol withdrawal seizure and required 24-hour medical detoxification treatment in the hospital as a result. He was at risk of even more severe and life-threatening withdrawal including delirium tremens as a result. He had active withdrawal symptoms including tremors, diaphoresis, intractable vomiting with blood, agitation, sleeping problems, headache, anxiety, and he had a CIWA score of 12. He reportedly also had medical issues including blood in his vomit, abdominal discomfort, increased acid reflux, acute kidney injury with an elevated creatinine of 1.37. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.