Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital treatment for alcohol detoxification treatment. The patient reportedly had alcohol withdrawal symptoms including elevated heart rate, tremors, nausea and vomiting with blood, anxiety, and had multiple falls due to alcohol use. The patient reportedly was drinking 1 pint of vodka daily and restarted use 10 days prior to admission. The patient's blood alcohol level (BAL) reportedly was 250. The patient reportedly had an abdominal computed tomography (CT) which showed hepatic steatosis suggestive of alcohol cirrhosis, and the patient had large amounts of ketones in their urinalysis (UA) as well as leukocyte esterase, blood, and bacteria. The patient reportedly had low potassium (K) of 3.3, low magnesium and phosphorus, and elevated lactate of 3.2. The patient reportedly was put on a Clinical Institute Withdrawal Assessment (CIWA) protocol and received intravenous (IV) Ativan. It was reported that the patient received Ativan 3 times on day 1, 6 times on day 2, and 3 times on day 3 but then left against medical advice (AMA). 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as they continued to use large amounts of alcohol daily including up to one pint of vodka per day and required detoxification medication including IV Lorazepam.  It was reported that the patient received and required Ativan 3 times on day 1, 6 times on day 2, and 3 times on day 3 but then left AMA. The patient still reportedly had elevated heart rate of 115 and required and received 3 more Ativan treatments for detoxification treatment but left AMA prior to completing their detoxification treatment. 
 
The patient was at medical risk of severe, complicated, and life-threatening withdrawal such as delirium tremens. The patient did require 24-hour inpatient medical hospital treatment for alcohol detoxification, and it was considered unsafe for them to be treated for detoxification in a less restrictive level of care then. The patient also was considered a high risk for relapse if not in this 24 hour inpatient hospital setting for detoxification treatment then and also had comorbid medical issues including hepatic steatosis suggestive of alcohol cirrhosis, and the patient had a medical history of cardiomyopathy, hypertension, pacemaker, and had low K of 3.3, low magnesium and phosphorus, and elevated lactate of 3.2, and had large amounts of ketones in their UA as well as leukocyte esterase, blood, and bacteria. The medical records provided enough specific evidence to support that he required inpatient hospital treatment for alcohol detoxification. 

Based on the above, the insurer's denial must be reversed. 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 an inpatient is substantiated.