Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse (withdrawal). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient in this case is an adult male. He presented to the emergency department with severe chest pain and request for detoxification in the context of a four-week binge with consumption of up to three bottles of vodka per day. At the time of presentation to the emergency department, the patient was evaluated with laboratory assessments, EKG (electrocardiogram) and Chest X-Ray, which revealed multiple abnormalities. He had low calcium, elevated glucose, and normocytic anemia with elevated liver functions. His Chest X-Ray showed vascular congestion later diagnosed as a recurrent pulmonary embolus after ruling out myocardial infarction. EKG (electrocardiogram) revealed normal sinus rhythm. The patient received Ativan and Librium in the emergency department and was admitted to inpatient level care where he received monitoring, fluid replacement, and supportive measures to address alcohol withdrawal. He presented with a blood alcohol level of 260 mg/dl (milligrams per deciliter) and a CIWA (clinical institute withdrawal 
assessment) scale score of 15. He was maintained on a CIWA (clinical institute withdrawal assessment) protocol. The patient has a history of pulmonary embolus from last year but was not taking his medications for prophylaxis or for hypertension-apixaban and amlodipine. The patient's clinical course progressed without incident. He quickly stabilized and declined additional services but with plans to proceed to rehabilitation treatment after the holidays- arranged by social work. Discharge diagnoses included pulmonary embolus, and alcohol use disorder and alcohol withdrawal, and hypertension. The health plan denied coverage for the requested services based on medical necessity and MCG (Milliman Care Guidelines) Guidelines indicating that the inpatient admission was not medically necessary. The treatment facility indicated that the requested services were medically necessary in keeping with the clinical features of the case and risk for complications of the pulmonary embolus and alcohol withdrawal, as well as effort to rule out myocardial infarction.

The Inpatient Hospital Admission was medically necessary. 

The hospital admission providing ongoing monitoring together with detoxification treatment and withdrawal management and other medical services could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol with a binge pattern of use with up to four weeks of heavy use of alcohol on a daily continuous basis, together with chest pain and history of recent pulmonary embolus that did warrant the admission and the continued inpatient level treatment. Detoxification, as necessary, and other treatments pertinent to the hospital stay could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided in the emergency department and at the time of admission. The patient's history of substance abuse (frequency and quantity) together with the general medical comorbidities do reflect the seriousness of the presenting clinical features and the need for further evaluation and monitoring while receiving a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures or encephalopathy if detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published societal guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below.