Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal symptoms

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is an adult who was admitted due to alcohol withdrawal symptoms including tremors, elevated heart rate of 119 beats per minute, nausea, elevated blood pressure of 150/108 mmHg, headache, palpitations, anxiety, tongue fasciculations, abdominal pain, and black watery stools. She also had gait problems and fell 1 day prior to admission. She was unable to eat or drink fluids on admission. It was reported that she was drinking 4-5 small bottles of vodka per day and was drinking alcohol to cope with stressors. It was reported that her blood alcohol level (BAL) on admission was 331. She reportedly had past outpatient treatment, frequent emergency department (ED) visits due to alcohol issues, and a past inpatient detoxification for alcohol. It was reported that her husband died 3 years prior to admission. She had a medical history significant for hypothyroidism and fatty liver. She was put on a Clinical Institute Withdrawal for Alcohol (CIWA) protocol and took Librium and Valium for detoxification 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 past or current 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 or current withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had reports of current and active alcohol withdrawal including tremors, elevated heart rate, nausea, elevated blood pressure, headache, palpitations, anxiety, tongue fasciculations, abdominal pain, and black watery stools. She reportedly had a history of heavy alcohol use and used it to cope with stressors. 

According to the Level of Care Determination, Office of Addiction Services and Supports (LOCADTR) the patient did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol and could not stop alcohol use which put her at risk of severe, complicated, and life threatening withdrawal. She did require 24 hour inpatient medical hospital treatment for detoxification treatment as she reportedly was prescribed 2 detoxification medications. She reportedly left AMA while still in active alcohol withdrawal. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.