Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This patient was admitted to this inpatient hospital treatment. He reportedly had severe intractable vomiting and nausea, hematemesis, mucosal sloughing, epigastric pain with guarding and rebound, chest pain, high anion gap metabolic acidosis, elevated liver function tests (LFT) and lactic acid, and reportedly drank 1 bottle of whiskey a few times per week and there was concern for a possible tear or rupture of the esophagus or peptic ulcer rupture. He reportedly had shortness of breath, alcohol ketoacidosis, gastroesophageal reflux (GERD), past COVID (coronavirus) pneumonia, hypertension, diabetes, and suspected alcohol gastritis. He reportedly was put on a Clinical Institute of Withdrawal Assessment (CIWA) protocol with Ativan intravenous (IV) as needed (prn), IV thiamine/folic acid, delirium tremens (DT) watch, and seizure precautions. He was later 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 need 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 several comorbid medical conditions complicating the management of withdrawal and he had reports of active alcohol withdrawal and was at risk for severe, complicated, and life-threatening withdrawal so he required inpatient hospital treatment. The risk of delirium tremens can occur 3-4 days after alcohol use and he reportedly was drinking large amounts of liquor including an entire bottle of whiskey a few days per week and reported drinking one bottle just prior to this admission. He was considered at risk for DT's due to his large amount of alcohol use and required 24-hour hospital treatment for CIWA protocol including IV Ativan prn, DT watch, seizure precautions, and IV thiamine/folic acid. He reportedly had multiple medical problems including severe intractable vomiting and nausea, hematemesis, mucosal sloughing, epigastric pain with guarding and rebound, chest pain, high anion gap metabolic acidosis, elevated LFT's and lactic acid, and there was concern for a possible tear or rupture of the esophagus or peptic ulcer rupture. 
He was considered at risk for more severe withdrawal and worsened medical issues if not treated in this hospital setting then.  

Inpatient hospital treatment was medically necessary.  It did not appear that the health care plan acted in the best interests of the patient then.

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