Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is overturned.

This patient was admitted to the inpatient hospital level of care due to alcohol detoxification; he also had severe chest pain and multiple episodes of intractable vomiting.  He reportedly had elevated heart rate over 120, multiple episodes of intractable, bloody, bilious vomiting, shakes and grossly visible tremors, nausea, tongue fasciculations, epigastric pain, weakness, dizziness, and had Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 11 and as high as 14. He reportedly was drinking half a gallon of vodka per day with the last reported drink one day prior to admission.  He reportedly had multiple medical issues including severe chest pain of 10 out of 10, low K (potassium), low MG (magnesium), elevated liver function tests (LFT's), anion gap and metabolic acidosis, ketones in his urine, alcohol gastritis and gastroesophageal reflux disease (GERD).  He reportedly had multiple past inpatient detoxification treatments and still could not stop severe alcohol use.  He reportedly was in the hospital 1 day prior to admission.  He reportedly was admitted to telemetry and had detoxification protocol with Ativan for detoxification daily and also reported was prescribed Librium.  He reportedly had intravenous (IV) fluids, thiamine, folic acid, and multivitamin.  He was discharged and refused the recommendation for inpatient alcohol rehabilitation treatment and social work intervention, as he stated that he would go by himself.

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.  

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 half a gallon of vodka per day, required and received detoxification medications (Lorazepam and also was prescribed Librium) each day to modify withdrawal from alcohol and prevent another withdrawal seizure of more complicated or life threatening withdrawal such as delirium tremens.  The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at high risk.  He received multiple doses of Ativan intravenous (IV) in the ER and still had withdrawal symptoms and medical issues.  He also reportedly had Ativan.  It was reported that he was given Ativan 1 milligram (mg) 3 times and Ativan .5 mg twice on the last admission date in question.  He also reportedly had multiple past inpatient detoxification treatments and still could not stop severe alcohol use and required inpatient alcohol rehabilitation treatment after this detoxification.  He reportedly did not have a sober living environment, as it was reported that his spouse had a substance use problem and also required detoxification treatment.  He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification at a less restrictive level of care then.  He required inpatient admission. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.

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