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 male patient was admitted for inpatient hospital treatment due to alcohol withdrawal symptoms including nausea, vomiting, and tachycardia. The patient had a Clinical Institute Withdrawal Assessment (CIWA) of alcohol score of 10. The patient had abdominal pain, melena, guaiac positive rectal examination, and shortness of breath. He presented with slurred speech and unsteady gait. The patient reportedly had past Intensive Care Unit (ICU) hospital treatment for alcohol withdrawal and had past reported seizures and was reported to be at high risk for alcohol withdrawal seizures and delirium tremens. The patient reportedly drank 1/2 pint of vodka. His past medical history was also significant for recurrent deep vein thrombosis (DVT). The patient was admitted and treated with Ativan 2 milligrams (mg) for withdrawal and then Librium for detoxification treatment. The patient left against medical advice (AMA) even though his detoxification treatment was not complete. 

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, or 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 could not safely be treated in a less restrictive setting as he had active alcohol withdrawal symptoms and comorbid medical conditions as well as past ICU treatment for alcohol withdrawal and past seizures. The patient was considered a high risk for more seizures and delirium tremens. The patient required and received 2 detoxification medications, including Ativan and Librium. The patient had a reported CIWA for alcohol score of 10, and had complaints of melena, abdominal pain, shortness of breath, and had recurrent DVT and past seizures and ICU treatment. The patient also had a guaiac positive test on rectal examination. The patient was considered at risk for severe, complicated, and life-threatening withdrawal from alcohol.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour hospital treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol despite past serious treatments including ICU stay and despite multiple medical issues including seizures and current bleeding. The patient required and received 2 detoxification medications to modify his withdrawal symptoms from alcohol. The risk of life-threatening withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues with active withdrawal symptoms. The patient left AMA but still received Librium for detoxification that day. The patient was considered a high risk medical patient. Thus, inpatient admission was medically necessary.  

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

Based on the above, the medical necessity for inpatient hospital admission is substantiated. The insurer's denial should be overturned.