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 was admitted due to alcohol withdrawal symptoms and medical problems. He reportedly had tremors, elevated blood pressure of 184/92, vomiting, muscle aches and cramping, and had rhabdomyolysis with a creatine kinase (CK) very high at 3749. He also reportedly had pleuritic chest pain. He reportedly was depressed due to the death of his girlfriend. He reportedly had been drinking up to 1.5 liters of tequila per day. He reportedly had past alcohol outpatient rehabilitation treatment. He reportedly was admitted to the medical unit and put on a Clinical Institute Withdrawal Assessment (CIWA) protocol with Lorazepam prescribed for alcohol detoxification treatment, had continuous IV fluids, and IV antiemetics. 
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that he did not have severe withdrawal, past history of withdrawal seizures, and did not require inpatient hospital treatment then. They recommended a less restrictive level of care then.
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required this level of care then. 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 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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)  he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily including up to 1.5 liters of tequila daily and he had active withdrawal symptoms including CIWA of 12 and required detoxification medication (Lorazepam) to modify withdrawal from alcohol and more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for DT's due to his large amount of alcohol use daily with active withdrawal symptoms. 

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 an inpatient admission is substantiated.