Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhabdomyolysis
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned

The patient is an adult male. He presented to an emergency department in poor physical condition after having stopped heavy use of alcohol five days prior to presentation. At the time of presentation to the emergency department, the patient gave a history of severe alcohol withdrawal symptoms in the past, as well as withdrawal seizures in the past and immediately prior to presentation. The medical screening had revealed evidence for rhabdomyolysis and elevated liver functions including hypokalemia and elevated creatinine kinase, as well as elevated blood pressure and heart rate with tachycardia and tachypnea. The examination revealed withdrawal symptoms including shaking, tremors, headache, body aches and restlessness with anxiety. The patient is single and homeless. The patient was treated in the emergency department and admitted for inpatient treatment with management of the rhabdomyolysis and a detoxification protocol, supportive measures, and withdrawal management. He received dosages of diazepam per the CIWA (clinical institute withdrawal assessment) protocol. The patient's hospital course progressed, but not without incident. His vital signs remained abnormal requiring monitoring due to persistent tachycardia. His Chest X-ray and CT (computed tomography) scan of the head were normal; he had sinus tachycardia on EKG (electrocardiogram). The patient showed mild tremors, anxiety, restlessness, and insomnia with persistently mild symptoms of withdrawal and muscle aches that diminished throughout his brief hospital course. The patient stabilized and arrangements were being made for a referral to rehabilitation substance use disorder treatment, which the patient declined, and outpatient follow up with disposition to a 
friend's home in the community. He was discharged on Day #4 with recommendations for clinically appropriate aftercare which was arranged including primary care appointment. The health plan denied coverage for the requested services based on MCG (Millman Care Guidelines) Guidelines indicating that the patient could have been sufficiently managed with lower-level care (observation level) for the dates of service under review. 

The Inpatient admission was medically necessary.

The requested benefit of inpatient admission for detoxification treatment and withdrawal management and monitoring and other medical services to address rhabdomyolysis were warranted in this case scenario. The patient in this case was using large quantities of alcohol with a presentation and history that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring together with supportive measures to manage the rhabdomyolysis including the need for IV (intravenous) hydration with electrolyte replacement and monitoring.
The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors (homelessness) and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management and stabilization, as the patient was at high risk for treatment failure or general medical complications such as seizures or complications of the rhabdomyolysis if detoxification and withdrawal management were to be attempted at a lower level of care. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, as well as NY (New York) State instruction for this review and the application of NY (New York) OASAS (New York Office of Addiction Services and Supports) 
LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria.