Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification

Treatment hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned.

This is the case of an adult male who was admitted to this inpatient hospital for alcohol detoxification. He had alcohol withdrawal symptoms including tremors, sweats, elevated heart rate of 96, elevated blood pressure, elevated temperature of 100.1, restlessness, anxiety, and dizziness. The patient had an initial Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 7 which then increased to 10. He was put on a Librium protocol for detoxification treatment. The patient reportedly had past inpatient detoxification treatments in which he took Librium for alcohol and benzodiazepine withdrawal. He was given Librium for tremors during a hospitalization. The patient had a diagnosis of alcohol use disorder. He also had hypertension and asthma. The patient reportedly lived alone. He was also given intravenous (IV) thiamine and folic acid. The patient was discharged.
  
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. 

This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to his large amount of daily alcohol use. He reportedly had active alcohol withdrawal symptoms including tremors, sweats, elevated heart rate of 96, elevated blood pressure, elevated temperature of 100.1, restlessness, anxiety, and dizziness. He reportedly had an initial CIWA of 7 which then increased to 10 so the withdrawal symptoms were worsening which put him more at risk medically and in need of inpatient hospital detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use a large amount of alcohol and he required and needed detoxification medication, Librium, to modify withdrawal. He needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting including severe and life-threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient hospital detoxification treatment. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the decision to deny coverage as the medical records provided enough specific evidence to support that he required this level of care.

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