Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal symptoms
 
Treatment: Inpatient hospital treatment

The insurer denied coverage for Inpatient hospital treatment. The denial is reversed. 

This patient is a female who was admitted to inpatient hospital treatment due to dizziness and severe abdominal pain. She reported abdominal pain 10 out of 10, a spinning sensation, weakness, decreased appetite, nausea and vomiting, elevated heart rate of 102, and blood pressure of 133/87. She had microcytic anemia and vitamin D deficiency, increased WBC and elevated glucose. Medically, she had a reported history of hypertension, diabetes, and gastric bypass. She had a history of alcohol use and depression. She reportedly was being monitored for alcohol withdrawal. She reportedly had a psychiatric consultation. She reportedly was treated with IV fluids, H2 inhibitors, antiemetics, Zofran, and B12. She reportedly was discharged.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as this was a high risk patient for alcohol withdrawal including possible complicated and life threatening withdrawals. She had nausea and vomiting, elevated heart rate, and this could have been related to withdrawal. She was drinking large amounts of alcohol for several days non-stop which put her at high risk for severe alcohol withdrawal symptoms for several days after.

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 recent very heavy use of alcohol for several days nonstop which put her at risk for complicated withdrawal which also could be life threatening. She also had comorbid medical issues including dizziness and severe abdominal pain, spinning sensation, weakness, decreased appetite, nausea and vomiting, elevated heart rate of 102, and blood pressure of 133/87. She reportedly had microcytic anemia and vitamin D deficiency, increased WBC and elevated glucose. Medically, she had a reported history of hypertension, diabetes, and gastric bypass. She reportedly required and was being monitored for alcohol withdrawal.

According to the LOCADTR she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she used large amounts of alcohol for several days nonstop days which put her at high risk for severe and complicated possibly life threatening withdrawal while also having comorbid medical issues. She needed 24 hour treatment then as she was at risk for possible life threatening withdrawal such as delirium tremens as this can occur 3-4 days and even up to 1 week after cessation of large amounts of alcohol use, and this patient had a long history of alcohol use with recent heavy alcohol use. Also, she could not stop drinking recently and had medical issues likely related to that so treatment outside of a 24 hour setting likely would have resulted in a relapse of drinking alcohol again, and also was not considered safe as she required medical hospital treatment to monitor withdrawal and the possibility of severe, complicated, and life threatening withdrawal in addition to worsened medical issues related to drinking alcohol.

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

The insurer's denial is reversed medical necessity is substantiated.