Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal seizure
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

The patient was admitted to an inpatient hospital due to a reported alcohol withdrawal seizure and for detoxification treatment. He reportedly was using alcohol and had a diagnosis of alcohol abuse. The diagnosis was alcohol withdrawal seizure and he reportedly received IM (intramuscular) Ativan and was put on an Ativan protocol for detoxification treatment and also was loaded with Keppra. He reportedly had a history of alcohol withdrawal seizures, seizures due to a past gunshot wound, diabetes, hypertension, GERD (gastroesophageal reflux disease), and a past CVA (cerebral vascular accident). He reportedly was also using cocaine and had a positive toxicology for cocaine and benzodiazepines. He reportedly was non-compliant with medications. He reportedly was also given thiamine. He reportedly signed out AMA (against medical advice) despite the recommendation to continue inpatient alcohol detoxification treatment and then inpatient alcohol rehabilitation treatment. 

The APA (American Psychiatric Association) 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. 

In this case, this patient had reports of an alcohol withdrawal seizure which requires inpatient medical hospital detoxification treatment. He was considered at risk for even more severe withdrawal or 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 severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment then. He also was using cocaine and had medical conditions including hypertension, diabetes, and a past CVA constituting more risk. According to the LOCADTR (level of care determination), 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 alcohol and required and received detoxification medication including Ativan IM and an Ativan taper protocol to prevent another withdrawal seizure or more severe or life threatening withdrawal such as delirium tremens. 

He was considered at high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment. The recommendation was then for inpatient alcohol rehabilitation treatment which he refused. 

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

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