Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: acute inpatient stay

The insurer denied coverage for acute inpatient stay. The denial is reversed. 

This patient is a female who was admitted to this inpatient hospital for alcohol detoxification. The patient was noted to have active withdrawal symptoms including tremors, diaphoresis, severe nausea and severe vomiting, nervousness, tactile hallucinations, dizziness, and elevated heart rate of 121 beats per minute. The patient was also noted to have low potassium level and a prolonged QTc interval on the patient's electrocardiogram (EKG). The patient's potassium level was 3mmol/L. The patient's history was significant for alcohol withdrawal seizures in the past. The patient's Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 12 and then 15-16. The patient required intravenous (IV) Ativan 4 mg in the Emergency Room (ER) and then Ativan taper protocol before the patient was stable for discharge.

The 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. Also, the US 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 past reported alcohol withdrawal seizures which required inpatient medical detoxification treatment and also had active significant alcohol withdrawal symptoms requiring inpatient hospital detoxification.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as the patient continued to use large amounts of alcohol, and required IV detoxification medication (Lorazepam) to modify the patient's withdrawal symptoms from alcohol and to prevent the patient from withdrawal seizure or more complicated or life threatening withdrawal, such as delirium tremens. The risk of delirium tremens can occur 4 days after alcohol use. The patient was considered at high risk for delirium tremens because of her past history of experiencing withdrawal seizure. The patient required 24 hour medical hospital treatment for alcohol detoxification. The patient required at least the entire days.

It did not appear that the health care plan acted reasonably with sound medical judgment, or in the best interests of the patient.

The carrier's denial of coverage for the acute inpatient stay is reversed.  The medical necessity is substantiated.