Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol Intoxication
 
Treatment:  Inpatient Admission 

The insurer denied the Inpatient Admission.  The denial was reversed.  

This is a female patient who presented to the emergency room (ER) for alcohol intoxication.  It was reported that she had issues with housing.  Her presenting symptoms included slurred speech, tremors.  She had a blood alcohol level (BAL) of 132. She received multiple injections of Ativan and thiamine throughout her day admission to the hospital.  She was transferred to an inpatient substance abuse rehabilitation facility for further treatment.
 
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment for alcohol detoxification, as the chart notes provided enough specific evidence to support that she required this level of treatment.  The 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.  In this case this patient had been drinking large amounts of alcohol and had withdrawal symptoms and had multiple medical issues including cirrhosis, gastro-esophogeal reflux disorder (GERD), and hip pain due to an assault.  She was considered a high risk for more severe, complicated, and life threatening withdrawal and required a significant amount of detoxification medication of Ativan to prevent worsened withdrawal. 

According to the LOCADTR, she did require 24-hour treatment, as she could not safely and effectively be treated in outpatient detoxification settings, as she continued to use alcohol despite medical issues and depressed mood with crying, and she required detoxification medication of Ativan to modify withdrawal and needed 24-hour treatment then, as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting at that time, including severe and life threatening withdrawal symptoms.  It was reported that she had detoxification medication (Ativan) 2 mg 4 times upon admission and Ativan 1.5 mg 3 times the next day and Ativan twice on the day of discharge, and she was then discharged to an inpatient substance rehabilitation treatment.  She was homeless and sleeping in her car and lacked coping skills and support for outpatient treatment.  It was unlikely that she would remain abstinent while still having withdrawal symptoms, so she required the time in this treatment to stop withdrawals and decrease the chance that she would relapse again when not in this 24-hour setting and also to prevent possible life threatening withdrawal symptoms including delirium tremens.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, so she required the entire time in this hospital.  She was discharged directly to an inpatient substance rehabilitation treatment.  She required a significant amount of detoxification medication of Ativan throughout her hospital stay, so she required 24 hour hospital detoxification treatment as she was considered a high risk for more severe, complicated, and life threatening withdrawal, and she had comorbid medical conditions as well.  She also was without a home.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.