Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance withdrawal.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This adult patient was admitted to this inpatient hospital due to alcohol withdrawal symptoms. The patient had coffee ground emesis, nausea, elevated heart rate of 117, epigastric pain, and was in significant distress. The patient had a history of past alcohol withdrawal seizures. The patient also had a medical history significant for gastritis, pancreatitis, anemia, lactic acidosis, and had critical lactic acid levels of 8.4. The patient also had low potassium (K) and magnesium (Mg) levels and required supplementation. The patient reportedly was drinking 2 liters of vodka per day. The patient was given Valium and Phenobarbital for detoxification treatment. The patient received intravenous (IV) fluids, Pepcid, Reglan, Protonix, and was on seizure precautions. The patient still had vomiting during the stay. When the patient was able to tolerate an oral diet and the vomiting stopped and nausea improved, the patient was discharged.

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. The 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 of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had active alcohol withdrawal symptoms including coffee ground emesis, nausea, elevated heart rate of 117, epigastric pain, and was in significant distress. The patient had a history of past alcohol withdrawal seizures. The patient required hospital detoxification treatment. Furthermore, the patient had a medical history significant for gastritis, pancreatitis, anemia, lactic acidosis, and had critical lactic acid levels of 8.4 as well as low K and Mg levels which required supplementation. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient did require 24 hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting as the patient continued to use large amounts of alcohol daily including up to 2 liters of vodka per day, required and received IV detoxification medications (Valium and Phenobarbital) during the stay to modify withdrawal from alcohol and prevent another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at high risk. The patient also continued to have vomiting and inability to tolerate anything by mouth during the hospital stay until discharge. The patient did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe to be treated for detoxification in a less restrictive level of care. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.