Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of what appears to be an alcohol withdrawal seizure (AWS) and tiny subdural hematoma along the tentorium. The patient was evaluated and released after a single night. The request is for inpatient admission, which is under medical necessity review.

Hospital notes state that the patient has a medical history of anxiety, depression, and hypothyroidism and presented for possible seizure activity. The patient was found on the floor convulsing and foaming at the mouth, lasting approximately three to five minutes. The patient reports they drink rather heavily but has no history of prior alcohol withdrawal seizures. The patient was evaluated and released after a single night. Medical records provided for review did not support the inpatient admission. The patient could have been treated at a lower level of care such as observation. Therefore, the inpatient admission was not medically necessary.

"Alcohol withdrawal symptoms may include anxiety, tremors, nausea, insomnia, and, in severe cases, seizures and delirium tremens. Although up to 50% of individuals with alcohol use disorder present with some withdrawal symptoms after stopping drinking, only a small percentage requires medical treatment for detoxification, and some individuals may be able to reduce their drinking spontaneously. Medical treatment may take place either in an outpatient or, when clinically indicated, inpatient setting. In some cases, clinical monitoring may suffice, typically accompanied by supportive care for hydration and electrolytes and thiamine supplementation. For those patients in need of pharmacological treatment, benzodiazepines (e.g., diazepam, chlordiazepoxide, lorazepam, oxazepam, and midazolam) are the most commonly used medications to treat alcohol withdrawal syndrome. Benzodiazepines work by enhancing the effect of the gamma-aminobutyric acid (GABA) neurotransmitter at the GABA-A receptor. Notably, benzodiazepines represent the gold standard treatment, as they are the only class of medications that not only reduces the severity of the alcohol withdrawal syndrome but also reduces the risk of withdrawal seizures and/or delirium tremens. Because of the potential for benzodiazepine abuse and the risk of overdose, if benzodiazepine treatment for alcohol withdrawal syndrome is managed in an outpatient setting, careful monitoring is required, particularly when combined with alcohol and/or opioid medications" (Witkiewitz et al., 2019) 

"Because alcohol dependence has become a major public health problem in the United States, many hospitals face challenges in treating patients with AWS, which is characterized by a wide array of symptoms including autonomic hyperactivity, tremor, agitation, hallucination, and seizures. Delirium tremens (DTs), an acute episode of delirium caused by alcohol withdrawal, is the most severe form of AWS, potentially leading to intensive care unit (ICU) admission or death. Some studies estimate that 3% to 5% of hospitalized patients with AWS progress to DTs" (Mo et al., 2018).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for the inpatient admission is not substantiated.