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 the inpatient hospital treatment setting on due to alcohol detoxification.  He reportedly had alcohol withdrawal symptoms including tremors, nausea, dry heaving, high blood pressure of 170/106, heart rate over 100, elevated respiratory rate, and he had reports of medical issues including abdominal pain and rectal bleeding, elevated liver function tests (LFT's), fatty liver, low Mg [magnesium], and he had a medical history of sleep apnea and chronic obstructive pulmonary disease (COPD). He reportedly had 17.5 milligrams (mg) of Ativan during his hospital stay for detoxification 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 comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at high risk for severe, complicated, and life threatening withdrawal due to his severe alcohol use, and also was at risk medically due to multiple medical problems along with his alcohol use.  He reportedly had high Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 15 on day 1 of admission and 13 on day 2 of admission and 5 on day 3 of admission. 

He reportedly had multiple medical issues including abdominal pain and rectal bleeding, elevated LFT's, fatty liver, low Mg, and he had a medical history of sleep apnea and COPD.  He reportedly had 17.5 mg of Ativan during his hospital stay for detoxification treatment which is a very large dose.  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 setting other than an inpatient medical detoxification setting as he continued to use large amounts of alcohol including 2 half pints of tequila and 1 large bottle of rum daily and had active withdrawal symptoms including tremors, nausea, dry heaving, high blood pressure of 170/106, heart rate over 100, elevated respiratory rate, and required and received large amounts of detoxification medication including 17.5 mg of Ativan for detoxification during his stay.  He also had reports of medical issues including abdominal pain and rectal bleeding, elevated LFT's, fatty liver, low Mg, and he had a medical history of sleep apnea and COPD.  He was at high risk for life complicated withdrawal such as delirium tremens as this can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues as well including very high blood pressure which also required Clonidine treatment. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient. 

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