Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient was admitted to this inpatient hospital due to altered mental status while drinking large amounts of alcohol. He was drinking large amounts of alcohol daily including liquor and beer. He had multiple medical problems including elevated blood pressure of 166/92, elevated troponin, hemoglobin (Hb) of 9.2, hematuria, and elevated creatinine. He had a significant medical history of seizures, chronic renal disease, hypertension, prior myocardial infarction and stroke, and coronary artery disease. He reportedly had multiple emergency room (ER) visits and a past admission for alcohol use and altered mental status. He reportedly lived in a shelter and was brought in by emergency medical services (EMS). He reportedly had 1000 mg (milligrams) of keppra, IV (intravenous) hydration, thiamine, folic acid, was put on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, telemetry monitoring, seizure precautions, and had cardiac enzymes monitored. He reportedly refused the recommendation to be discharged to a substance inpatient rehabilitation treatment and accepted outpatient referrals. 
  
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. 

The patient had several comorbid medical conditions complicating the management of withdrawal and he had past reported seizures as well as altered mental status on admission and was at risk for severe, complicated, and life-threatening withdrawal so he required inpatient hospital treatment. The risk of delirium tremens can occur 3-4 days after alcohol use and he reportedly was drinking large amounts of liquor and beer daily, so he was considered at risk for delirium tremens (DT) due to his large amount of alcohol use daily. He reportedly had multiple medical problems including elevated blood pressure of 166/92, elevated troponin, Hb of 9.2, hematuria, and elevated creatinine. He reportedly had a significant medical history of seizures, chronic renal disease, hypertension, prior myocardial infarction and stroke, and coronary artery disease. He reportedly had multiple ER visits and a past admission for alcohol use and altered mental status. He was put on a CIWA protocol, given 1000 mg of keppra, intravenous (IV) hydration, thiamine, folic acid, had telemetry monitoring, seizure precautions, and had cardiac enzymes monitored. He did require 24-hour medical hospital treatment for alcohol detoxification treatment and medical treatment, and it was considered unsafe for him to be treated in a less restrictive level of care then and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues and alcohol treatment issues needed which required hospital treatment then. He also was reportedly living in a shelter and lacked supports. 

This patient had multiple medical issues and medical history and was drinking large amounts of alcohol and required hospital treatment for altered mental status and CIWA protocol. He was considered at risk for more severe withdrawal and worsened medical issues and could not care for basic needs due to his altered mental status in the context of alcohol use, so he required 24-hour inpatient hospital treatment. 

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 inpatient admission is overturned. Medical Necessity is substantiated.