Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.  The denial is overturned. 

This is a male patient who was admitted to inpatient hospital treatment due to alcohol withdrawal. He reportedly had alcohol withdrawal symptoms including multiple episodes of vomiting, nausea, shakes, increased heart rate, and had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 5. The patient reportedly was drinking several bottles of vodka daily and reported drinking 3 pints of vodka 2 nights prior to admission. The patient reportedly had medical issues also including elevated liver function tests (LFTs) likely secondary to alcohol hepatitis, low potassium, low magnesium, and hypertension. The patient reportedly was given 100 milligram (mg) of Librium for detoxification in the Emergency Department (ED) as well as 45 mg of Valium, 10 mg of Reglan, and 2 liters of intravenous (IV) fluids. The patient reportedly also was given antihypertensive medication. The patient continued with detoxification medication as he was put on an Ativan taper, and was discharged with referrals to rehabilitation treatments.

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. In this case this patient had been drinking large amounts of alcohol daily, and had active alcohol withdrawal symptoms including multiple episodes of vomiting, nausea, shakes, increased heart rate, and had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 5. 

Based on the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings or less restrictive settings other than 24-hour hospital treatment as he continued to use large amounts of alcohol daily despite medical issues including elevated liver enzymes likely secondary to alcohol hepatitis, low potassium and low magnesium, and hypertension, as well as abnormal electrocardiogram. The patient required and received detoxification medications including Ativan and Librium to modify withdrawal. The patient required 24-hour treatment as he was at risk for worsened withdrawal, including severe and life-threatening withdrawal symptoms. It was unlikely that the patient would have remained abstinent while having withdrawal symptoms and active comorbid medical issues. The patient required the time in this treatment setting in order to stop his withdrawal symptoms, and to decrease the chance that he would relapse again. The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use; so, this patient required the entire time in this hospital. The recommendation was for alcohol rehabilitation after discharged and he was given referrals reportedly.  

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient was at high risk for life-threatening withdrawal symptoms, and had active withdrawal symptoms with comorbid medical issues and required detoxification medications until discharged. 

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the Inpatient Hospital Admission should be overturned.