Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned

This male patient was admitted to this inpatient hospital treatment detoxification unit. He walked in requesting detoxification from alcohol and reportedly was drinking 1 liter of vodka per day. He had elevated heart rate of 125-132, nausea, vomiting, diarrhea, malaise, chills, cramps, sleeping problems, yawning, and decreased appetite. He reportedly had rhabdomyolysis and elevated creatinine kinase (CKT) thought to be related to alcohol withdrawal. He had prolonged QTc (interval on EKG [electrocardiogram]) of 499 and had an EKG show nonspecific ST (interval on EKG) changes in inferior leads. He had low magnesium. He had 3 past inpatient detoxification treatments. He was put on a detoxification protocol and prescribed Librium/Ativan prn (as needed) as needed, given (intravenous) IV fluids, thiamine, folic acid, and Metoprolol for tachycardia. He was discharged when considered hemodynamically and clinically stable.
   
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 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.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), 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 large amounts of alcohol daily including up to 1 liter of vodka daily and he had reports of elevated heart rate of 125-132, nausea, vomiting, diarrhea, malaise, chills, cramps, sleeping problems, yawning, and decreased appetite. He was prescribed a Librium/Ativan protocol as needed for detoxification needs. The medical records stated that he was at potential risk of moderate to severe withdrawal due to his high tolerance and history of rapid development of tolerance. The risk of delirium tremens (DT) can occur 3-4 days after alcohol use so he was considered at risk for DT's due to his large amount of alcohol use daily and active medical issues. He did require 24 hour medical hospital treatment for alcohol detoxification and medical treatment and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then and also unsafe for him to be treated medically outside of a hospital setting due to his medical issues and risk of moderate to severe withdrawal due to his large amount of daily alcohol use, past treatment episodes requiring inpatient detoxification treatment, and due to medical issues requiring hospital treatment.

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

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