Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This patient was admitted to this hospital due to medical complaints and withdrawal symptoms. He had severe epigastric pain 10 out of 10, vomiting, nausea, dizziness, tremors, tongue fasciculations, elevated heart rate and elevated blood pressure, and fever with lactate. He had alcohol pancreatitis and hepatomegaly. Bloodwork showed low potassium (K), low Magnesium (Mg), elevated lipase and elevated blood alcohol level. He reportedly was given Ativan intravenously (IV) for withdrawal and put on an Ativan Clinical Institute Withdrawal Assessment for alcohol (CIWA) protocol. Gabapentin was also prescribed as needed for withdrawal. He had intravenous (IV) fluids, thiamine, folic acid, and vitamin B12 (Cobalamin). He was in rehabilitation treatment prior to this hospitalization. He did not want to return for alcohol rehabilitation treatment at that facility, so he was given other alcohol rehabilitation treatment options and was discharged. 
   
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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to large amounts of alcohol use and had comorbid medical issues complicating the management of withdrawal. He had alcohol withdrawal symptoms and medical conditions including severe epigastric pain 10 out of 10, vomiting, nausea, dizziness, tremors, tongue fasciculations, elevated heart rate, elevated blood pressure, and fever with lactate. He had alcohol pancreatitis. He also reportedly had low K and low Mg, elevated lipase, and hepatomegaly. 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 in a less restrictive treatment setting. He continued to use large amounts of alcohol despite medical issues and past inpatient alcohol rehabilitation treatment as he was in an inpatient alcohol rehabilitation treatment prior to this admission and still relapsed. He required and needed detoxification medication to modify withdrawal including Ativan intravenous push (IVP) and Ativan CIWA protocol and Gabapentin as needed for withdrawal. The risk of complicated withdrawal such as delirium tremens can occur 3 to 4 days after alcohol use so he required inpatient detoxification protocol treatment, The patient was at risk medically for more severe, complicated, and life-threatening withdrawal with active medical issues putting him at risk and required 24- hour hospital treatment. 

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

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