Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed.   

This is a male patient with a history of cirrhosis, esophageal varices, liver disease, cerebrovascular disease, traumatic brain injury (TBI), hypertension, and hepatic encephalopathy. He presented to the hospital with complaints of epigastric pain rated 10/10 in severity and alcohol withdrawal symptoms that included confusion, tremors, disorientation, and agitation. His Clinical Institute Withdrawal Assessment (CIWA) score for alcohol was 16. It was reported that the patient was unable to care for his basic needs or perform his activities of daily living (ADL). Throughout the patient's hospitalization the patient remained agitated, disoriented and confused, and unable to care for self. He was treated with alcohol withdrawal protocol until he was discharged to a skilled nursing facility.

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. 

This patient could not safely have been treated in a less restrictive setting than a 24-hour medical hospital treatment because the patient presented with clinical concern for complicated withdrawal symptoms including possible delirium tremens verses encephalopathy, and was unable to care for his basic needs. During the inpatient stay, the patient was continued on Ativan treatment for withdrawal and agitation and also required Haldol as well and intravenous fluid treatment. The patient was noted to be disoriented, confused, agitated, and unable to care for self. The patient had multiple medical issues including cirrhosis, esophageal varices, liver disease, cerebrovascular disease, traumatic brain injury (TBI), hypertension, and hepatic encephalopathy, anemia, low platelets, low magnesium, high amylase, and cerebral atrophy. 

The patient continued to receive treatment for alcohol withdrawal and was discharged when the patient became more alert and able to communicate better. In this case this patient had been drinking large amounts of alcohol daily with multiple serious medical issues related to his alcohol use.  According to the LOCADTR criteria, the patient required 24-hour treatment because he could not safely and effectively be treated in a less restrictive detoxification setting due to his unrestrained, continued use of large amounts of alcohol daily despite medical issues. The patient was at high risk for complicated withdrawal and needed detoxification medications to modify the withdrawal symptoms. This treatment required inpatient detoxification, and 24-hour monitoring to prevent life threatening withdrawal symptoms. During this patient's inpatient detoxification, the patient required multiple medications to treat this patient's withdrawal symptoms and agitations. The patient was treated with intramuscular Lorazepam as well as Ativan and Haldol. 

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

The carrier denial of coverage for inpatient hospital admission is reversed. The medical necessity is substantiated.