Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol abuse

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male patient was admitted for inpatient hospital treatment of alcohol detoxification. The patient initially presented with hyponatremia, chest pain, and withdrawal symptoms including increased heart rate and blood pressure and tremors. The patient reportedly had severe depression, as well. It was reported that he had a 90-day binge drinking of about 40 plus beers per day, and drank all day every day. The patient had past reported detoxification treatment. The patient was admitted and was started on a Librium protocol for detoxification treatment. The patient was also treated with Zoloft for depression. The patient was stabilized and then 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. 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. In this case, this patient could not have been safely treated in an outpatient detoxification as he had active alcohol withdrawal symptoms including increased heart rate and blood pressure and tremors in the context of very heavy alcohol use. The patient was drinking 40 plus beers per day and was drinking all day every day, and was at high risk for severe, complicated, and life threatening withdrawal from alcohol, such as delirium tremens. The patient also had severe depression and comorbid medical condition such as hyponatremia that required medical attention. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not have been safely and effectively treated for his detoxification in a less restrictive setting. The patient continued to use large amounts of alcohol despite past his most recent inpatient treatments. The patient also required and received detoxification medication to modify withdrawal; the patient was on the Librium protocol and needed an additional dose of Librium during admission due to his uncontrolled withdrawal symptoms. As per medical note, the patient had withdrawal symptoms including tremors and anxiety and had to continue treatment with the Librium protocol. It was reported that the patient continued with the Librium protocol throughout the hospital stay and then was discharged. Thus, the inpatient hospital stay was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital stay is substantiated. The insurer's denial should be overturned.