Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal Seizure

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This patient was admitted to this inpatient medical hospital due to abdominal pain, vomiting, nausea, diarrhea, dizziness, hiccups, fatigue, increased heart rate of 115, and had a past history of alcohol withdrawal seizures and reportedly had dysphagia and was unable to swallow or tolerate fluids and had a 50 lb (pound) weight loss and severe malnutrition. The patient had electrolyte abnormalities including low sodium (Na), low potassium (K), and low magnesium (Mg) and required supplementation. The patient had ST (interval electrocardiogram (EKG)) depression on EKG. Heavy alcohol use, up to 4 shots per day and more use since the death of the patient's mother. He reportedly was put on a Clinical Institute of Withdrawal Assessment (CIWA) protocol with Ativan as he had past withdrawal seizures and likely current withdrawal symptoms including nausea and vomiting, elevated heart rate of 115. The patient reportedly left against medical advice (AMA). 
  
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 or less restrictive levels of care, 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 current or 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 (United States) 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. In this case this patient had past complicated severe withdrawal as he had an alcohol withdrawal seizure in the past and required 24-hour medical detoxification treatment in the hospital as a result. He was at risk of even more severe and life-threatening withdrawal including delirium tremens as a result. He had likely also had active withdrawal symptoms including nausea and vomiting, elevated heart rate of 115, and he reportedly had comorbid medical issues as well including abdominal pain, dysphagia, 50 lb weight loss, severe malnutrition, low sodium (Na), low potassium (K), and low magnesium (Mg).

The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this especially with his heavy daily alcohol use and past withdrawal seizure and he had multiple medical issues.   He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care. He reportedly was on a CIWA protocol with Ativan. He required at least the entire hospital stay. This was a high-risk patient who had a past alcohol withdrawal seizure which requires medical hospital detoxification treatment.  

Inpatient hospital treatment was medically necessary. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.

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