Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital on the telemetry unit due to alcohol withdrawal and the need for alcohol detoxification treatment. The patient reportedly fell and was found at home on the floor by their mother after drinking a liter of vodka. The patient reportedly was drinking 1 liter of vodka per day. The patient reportedly had active alcohol withdrawal symptoms including tremors, elevated heart rate of 100, elevated blood pressure of 163/96 and 150/101, anxiety/depression, body aches, and the patient had a Clinical Institute Withdrawal Assessment (CIWA) score of 13. It was reported that the patient had a past alcohol withdrawal seizure. The patient reportedly had past treatment episodes including one two weeks prior to admission for alcohol withdrawal treatment. The patient also reportedly had a hospitalization 1 month prior to admission after falling and breaking their jaw. The patient reportedly had a medical history significant for alcoholic pancreatitis, hypertension, anemia, and recent jaw fracture, in addition to a past alcohol withdrawal seizure. The patient reportedly had low potassium of 3.1, low phosphorus of 1.9, low magnesium of 1.4, elevated liver function tests (LFT's) of 99 for aspartate aminotransferase (AST) and 77 for alanine aminotransferase (ALT), and low phosphorus of 1.9. The patient reportedly had a 19 year history of alcohol use problems. The patient reportedly was given 2 detoxification medications including Librium 25 milligrams (mg) times 2 and then 50 mg every (q) 6 hours times 3 doses, and also intravenous (IV) Ativan 2 mg 1 time and an additional dose of IV Ativan .25 mg 1 time. The patient also reportedly was given IV fluids, magnesium, phosphorus, Zofran, and thiamine.  The patient reportedly was discharged when they were clinically stable without further alcohol withdrawal symptoms.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required this level of care then. 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. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is substantiated.