Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This adult was admitted to this inpatient hospital for alcohol detoxification treatment. She had alcohol withdrawal symptoms including nausea, vomiting, tremors throughout her extremities, tongue fasciculations, dry mucous membranes, anxious mood, elevated heart rate of 90-94, and elevated blood pressure of 147/89. She had high anion gap, metabolic acidosis, elevated liver function tests (LFTs), low platelets that kept dropping lower, low potassium (K) and low sodium (Na). She reportedly had been drinking two fifths of alcohol daily. She reportedly had a recent past alcohol detoxification hospitalization. She reportedly was given Phenobarbital daily for alcohol detoxification as well as Valium and Ativan intravenous (IV). She continued to have alcohol withdrawal symptoms throughout her entire hospital stay and continued with Phenobarbital and Valium as needed for alcohol detoxification. She reportedly requested to be discharged despite the recommendation to continue her alcohol detoxification at this hospital.
  
The insurer denied coverage for inpatient hospital treatment for alcohol detoxification treatment as not medically necessary treatment. They stated that she did not have signs of severe alcohol withdrawal which did not respond to treatment, and they recommended a less restrictive level of care.
  
The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment for alcohol detoxification treatment as the medical records provided did provide enough specific evidence to support that she required this level of care. 

In this case this patient had active alcohol withdrawal symptoms including nausea, vomiting, tremors throughout her extremities, tongue fasciculations, dry mucous membranes, anxious mood, elevated heart rate of 90-94, and elevated blood pressure of 147/89. She also had comorbid medical conditions complicating the management of withdrawal including high anion gap, metabolic acidosis, elevated LFTs, low platelets that kept dropping lower, low K and low Na. 

According to the Level of Care for Alcohol and Drug Treatment (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol daily including up to two fifths per day, required and received multiple detoxification medications including Phenobarbital daily, IV Ativan on day one, and as needed (prn) Valiums throughout her stay to modify withdrawal from alcohol. She reportedly continued to use large amounts of alcohol daily despite a recent inpatient hospital detoxification treatment. Notes reported that she had an elevated blood pressure of 132/91, abdominal pain of 7 out of 10, low platelets of 69, low Na of 132, low K of 3.1, and she required IV magnesium (Mg) and IV potassium. She reportedly took IV Thiamine and still had Phenobarbital 97.5 mg (milligrams) three times daily (TID) for alcohol detoxification. Notes reported that she had elevated blood pressure of 131/90 and still scored positive on the Clinical Institute Withdrawal Assessment (CIWA) scale. 

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

The medical necessity for an inpatient hospital admission is substantiated.