Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This young adult was admitted to this inpatient hospital due to multiple episodes of vomiting, abdominal pain, and tremors. She reportedly stopped drinking alcohol 3 days prior to admission. She had intermittent diarrhea also. She was put on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol for alcohol withdrawal treatment and detoxification. She was administered Ativan. She also had gastroenteritis. She had continued abdominal pain and nausea. She reportedly was drinking daily. She stopped drinking 3 days prior to admission due to vomiting. She was given intravenous fluids (IVF) and put on a clear diet, given intravenous (IV) Morphine for pain, and was given antibiotics, Cipro and also Flagyl, as well as Pepcid and Zofran. She had a past cholecystectomy. She was resistant to continued detoxification treatment and was given Serax 15 mg (milligrams) three times daily (TID) for 5 days for detoxification treatment when discharged.
    
The medical records did provide enough specific evidence to support that she required inpatient hospital 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. It also states that patients with 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 a comorbid medical condition that complicates 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 of delirium tremens, or if one does not have the capacity for informed consent. 

According to the Level of Care for Alcohol and Drug Treatment (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 alcohol daily and required and received detoxification medication, Ativan to modify withdrawal from alcohol and prevent severe, complicated, of life-threatening withdrawal. It was recommended that she continue in this hospital setting to complete detoxification treatment, but she requested to be discharged and was discharged with Serax 15 mg TID for 5 days to complete the detoxification treatment. She did require 24-hour medical hospital treatment for the entire stay in this hospital and it was considered unsafe for her to be treated 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 an inpatient admission is substantiated.