Appeal type: Medical necessity
Decision: Overturned

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

This male was admitted to this inpatient hospital for alcohol detoxification treatment. He reportedly had active alcohol withdrawal symptoms including elevated heart rate in the 120's, tremors, nausea, vomiting, headache, muscle weakness and aches, agitation, anxiety, sweats, elevated blood pressure, and a Clinical Institute Withdrawal Assessment Alcohol (CIWA) as high as 16. He reportedly was drinking 8-10 beers per day and had no recent long period of sobriety. He had past alcohol inpatient detoxification and rehabilitation treatment and past outpatient alcohol counseling. He reportedly had a family history of alcohol use. He had a diagnosis of Alcohol Use Disorder. He had hypertension and neuropathy. It was reported that his alcohol use caused financial and relational problems. It also was reported that his alcohol use resulted in medical injuries due to falling. He reportedly was living with his girlfriend. He was put on a Librium standing CIWA protocol and also received Ativan IV (intravenous)and oral (PO) as needed (PRN) for withdrawal. He continued to have alcohol withdrawal symptoms and left against medical advice (AMA) and refused the follow up recommendation for inpatient alcohol rehabilitation treatment.
    
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 could not stop use. He reportedly had increased use due to worsened depression after the death of his mother. 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 in a less restrictive treatment setting as he continued to use large amounts of alcohol daily despite alcohol use contributing to financial and relational problems and medical issues, and he required and needed detoxification medications to modify withdrawal, including Ativan and Librium, and needed 24 hour inpatient hospital treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting including severe and life threatening withdrawal symptoms such as delirium tremens. 

It was reported that he had detoxification medication including standing Librium and Ativan including 2 mg (milligrams) PO and still had active alcohol withdrawal symptoms and elevated CIWA scores of 11-14. It was reported that he still had a CIWA of 9 and active alcohol withdrawal symptoms including tremors, sweats, agitation, anxiety, and tactile disturbances, as well as elevated blood pressure. He reportedly asked to leave AMA and not complete the detoxification treatment and also refused the follow up for inpatient alcohol rehabilitation treatment after his detoxification treatment. He also continued to use alcohol daily in large amounts despite past alcohol inpatient detoxification and rehabilitation treatment and past outpatient alcohol counseling and lacked the coping skills to maintain abstinence without this inpatient hospital detoxification treatment setting. It was unlikely that he would remain abstinent while still having withdrawal symptoms so he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24-hour setting and also to prevent possible life-threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this hospital. 

As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient alcohol detoxification in this hospital. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient.  

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