Appeal type: Medical necessity
Decision: Overturned

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

This male patient has a history of alcohol abuse.

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. 
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 past withdrawal seizure and had current significant withdrawal symptoms including nausea, tremors, abdominal discomfort, weakness, chest pain, numbness, elevated heart rate of 96, elevated blood pressure of 168/81, and CIWA of 26. 
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 large amounts of alcohol daily despite medical issues and a past withdrawal seizure. He had significant current active alcohol withdrawal symptoms, and he required and needed 2 detoxification medications to modify withdrawal including Lorazepam 2 mg IVP with 2 doses and also was given Librium 50 mg one time. The patient also had multiple medical issues including feet and hand contractures, past withdrawal seizure, was immunocompromised, had gastroesophageal reflux, anemia, elevated LFT's, low K and low Mg. It was reported that his symptoms also were consistent with alcohol hepatitis. He also was given Gabapentin 300 mg to prevent seizures, Ondansetron IVP, and Famotidine IVP, and KCl 4 doses, as well as Colchicine for pericarditis and also given thiamine, folate, and multivitamin. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at high risk medically as he had active medical issues putting him at risk medically as well and required 24-hour hospital treatment.  
This was a very high-risk patient with multiple serious medical issues and significant active withdrawal symptoms with a CIWA (Clinical Institute Withdrawal Assessment for Alcohol scale) as high as 26 who required 2 detoxification medications to treat his withdrawal and also had a history of alcohol withdrawal seizures which requires inpatient hospital treatment.

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

The carrier's denial of coverage for the inpatient admission is overturned.  The medical necessity is substantiated.