Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

The patient is a male who was admitted to this inpatient hospital due to acute alcohol withdrawal and hypertensive emergency. He had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 14 and had active withdrawal symptoms including severe and progressive nausea and vomiting, uncontrolled hypertension as high as 184/133, agitation, tremors, headache, and anxiety. He had past alcohol withdrawal seizure and past delirium tremens (DTs). He reportedly was drinking 1 pint of vodka and beer daily. He reportedly also had other medical issues including hyperkalemia, low magnesium, gastritis, alcohol hepatitis, and prolonged QTc. He had past inpatient treatment for alcohol withdrawal and medical issues. He was given intravenous (IV) Ativan taper for a CIWA protocol for detoxification. He also reportedly was given IV Labetalol, Hydralazine, Famotidine, and IV fluids, and thiamine. He reportedly signed out against medical advice (AMA).
  
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.

The US (United States) 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 history of complicated severe withdrawal including alcohol withdrawal seizure and DTs with active acute withdrawal symptoms including severe and progressive nausea and vomiting, uncontrolled hypertension as high as 184/133, agitation, tremors, headache, and anxiety with a CIWA of 14. He was at risk for more severe and life-threatening withdrawal including delirium tremens and another withdrawal seizure and this required 24-hour hospital treatment. He also had comorbid active acute medical issues including severe uncontrolled hypertension which was considered a hypertensive emergency and he was at even greater risk medically and in need of 24-hour hospital treatment. He had other reported medical issues including hyperkalemia, low magnesium, gastritis, alcohol hepatitis, and prolonged QTc (interval on EKG [electrocardiogram]). 
This was a high-risk patient who had a past alcohol withdrawal seizure and DTs which requires medical hospital detoxification treatment, and he had active severe comorbid medical conditions including hypertensive emergency

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.