Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is the case of a female patient who was admitted to this inpatient hospital treatment due to alcohol withdrawal symptoms. She reportedly had withdrawal symptoms including multiple episodes of vomiting, nausea, tremors, agitation, headache, anxiety, weakness, and visual sensitivity and had a Clinical Institute Withdrawal Assessment (CIWA) for alcohol of 17. She reportedly was drinking 2 bottles of wine and a six pack of beer per day for the past month. She reportedly had a past history of crack/cocaine use and past inpatient substance rehabilitation treatment. She reportedly was immunocompromised. She reportedly relapsed when her boyfriend was drinking but reported that he was physically abusive so they ended the relationship. It was reported that she had a history of abuse. The patient had Librium 25 milligrams (mg) every 8 hours on day 1 and then Librium 25 mg every 12 hours day 2 and then it was discontinued as she only preferred Ativan or Klonopin orally and refused intravenous (IV) fluids and medications and vitamins. She took them but then left against medical advice (AMA). 

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. 

In this case this patient had active alcohol withdrawal symptoms including multiple episodes of vomiting, nausea, tremors, agitation, headache, anxiety, weakness, and visual sensitivity with a high CIWA of 17 and was at risk for severe, complicated, and life-threatening withdrawal so she required 24-hour medical hospital detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting. The patient continued to use large amounts of alcohol daily, required and received detoxification medications to modify withdrawal from alcohol, and she needed 24-hour treatment as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting including possible life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at risk for this. She had a past inpatient substance rehabilitation years ago for crack/cocaine use and had comorbid psychiatric issues including trauma issues and was immunocompromised. She was not considered safe for treatment outside of a 24-hour hospital setting and it was considered unsafe for her to have detoxification treatment in a less restrictive level of care. 

Inpatient hospital treatment for detoxification was medically necessary as the medical records provided enough specific evidence to support that she required this level of care. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient.

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