Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This adult male was admitted to this inpatient hospital after falling at home and fracturing 2 ribs and complained of pain that was 10 out of 10 and had difficulty breathing as well as alcohol withdrawal symptoms including visible tremors, nausea and vomiting, elevated heart rate up to 105, elevated blood pressure of 156/104, elevated respiratory rate of 24, dizziness. He had multiple medical issues needing treatment. He required 5 grams of intravenous (IV) magnesium as it was low and this was to resolve the prolonged QT (interval on EKG (electrocardiogram) interval. He had thrombocytopenia and low sodium. He also had alcohol neuropathy, atrial fibrillation, and hypertension. He was given 130 mg (milligrams) intravenous push (IVP) of Phenobarbital for detoxification treatment and required multiple doses of Phenobarbital in addition to 4 mg of Ativan for detoxification treatment. His Clinical Institute Withdrawal Assessment (CIWA) was up to 22, which was considered high with a blood pressure of 162/100, so he was still in alcohol withdrawal and at risk for worsened withdrawal. He left against medical advice (AMA).
  
The American Psychiatric Association 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 United States (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 of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had several comorbid medical conditions complicating the management of withdrawal and he had active alcohol withdrawal symptoms including visible tremors, nausea and vomiting, elevated heart rate up to 105, elevated blood pressure of 156/104, elevated respiratory rate of 24, dizziness, and he had multiple medical issues requiring hospital 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 drink alcohol with last use the day prior to admission and he had active withdrawal symptoms including a CIWA of 22 the next day. Risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for delirium tremens (DT) due to his alcohol use daily with active withdrawal symptoms. He had depression and took duloxetine and buspirone. He did require 24-hour acute 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 not advisable for him to be treated medically outside of a hospital setting. 

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 hospital admission is overturned. Medical Necessity is substantiated.