Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification. 
Treatment: Continued Inpatient Hospital Treatment. 

The insurer denied coverage for continued inpatient hospital treatment.

The denial is overturned.

This patient presented to the ED (emergency department) of this hospital and was admitted to this inpatient hospital for alcohol detoxification as he reportedly had active alcohol withdrawal symptoms including headache, vomiting, tremors, abnormal skin sensations, and had a past alcohol withdrawal seizure 1 1/2 weeks prior to this admission. He reportedly had low potassium of 2.7 and low magnesium of 1.3 and had elevated AST [Aspartate transaminase]/ALT [Alanine transaminase] of 350/106. He reportedly was given Ativan 2 mg (milligram) intravenous push (IVP) and then put on a detoxification protocol of Ativan 2 mg intramuscular (IM) every (q) 6 hours and Ativan 1 mg q (every) 8 hours prn (as needed) alcohol withdrawal. He also received IV potassium, thiamine, folic acid, and IV (intravenous) fluids. He also was managed for alcohol steatohepatitis. He was discharged home after refusing alcohol inpatient rehabilitation treatment. 
    
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. 

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 for detoxification in a less restrictive setting as he required and received detoxification medication including intravenous (IV) Ativan to modify withdrawal from alcohol and prevent another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this.  He did require 24 hour medical hospital treatment for alcohol detoxification and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He required at least the entire days as it was reported that he had a Clinical Institute of Withdrawal (CIWA) protocol with Ativan detoxification.  This was a high risk patient who had a recent withdrawal seizure which requires medical hospital detoxification treatment, and he had active comorbid medical conditions. He reportedly refused the recommendation for inpatient alcohol rehabilitation treatment and was discharged. This patient was considered high risk for delirium tremens. 

As a result, the recommendation is to overturn the previous decision and approve coverage for continued inpatient hospital treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then. 

Based on the above, the medical necessity for the Intensive Care Unit (ICU) level of care is substantiated. The insurer's denial is overturned.