Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence with withdrawal.
Treatment: Hospital admission at an acute inpatient level of care.
The insurer denied coverage for the hospital admission at an acute inpatient level of care.
The denial is overturned.

This is a male patient whose medical history included alcohol dependence, gastroenteritis, thrombocytopenia, anemia, tachyarrhythmia, trigeminal neuralgia, hepatitis steatosis, gastroesophageal reflux disease (GERD), and depression. The patient presented to the Emergency Room (ER) with withdrawal symptoms including tremors; vomiting; diarrhea; weakness; abdominal pain; and elevated blood pressure, heart rate, and respiratory rate. He was admitted for inpatient treatment for alcohol detoxification. 

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 safely be treated in an outpatient detoxification or a less restrictive level of care other than a hospital setting as he presented with active alcohol withdrawal symptoms and comorbid medical issues that put him at risk for more severe, life-threatening withdrawals, such as delirium tremens. 

Also, according to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated in an outpatient detoxification setting as he continued to use alcohol daily despite medical issues and he required and needed intravenous (IV) detoxification medication to modify his withdrawal symptoms. The patient needed 24-hour treatment as he was at risk for worsened withdrawal symptoms. The risk of life-threatening withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification protocol treatment. The patient also had active medical issues including tachyarrhythmia, hepatitis steatosis, GERD, gastroenteritis, thrombocytopenia, and anemia which can complicate this patient's alcohol withdrawal. The patient was appropriately admitted and treated on Clinical Institute Withdrawal Assessment (CIWA) for alcohol protocol with Ativan taper. Thus, inpatient admission 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 hospital admission at an acute inpatient level of care is substantiated. The insurer's denial should be overturned.