Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This female was admitted to inpatient rehabilitation and had alcohol withdrawal symptoms but was transferred to a medical floor with telemetry monitoring due to a significantly prolonged QTc (EKG [electrocardiogram] interval of 547 and low magnesium of 1.2. She had alcohol withdrawal symptoms including nausea and a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) as high as 6. She reportedly was drinking 1 bottle of wine or vodka daily for years. She also reportedly was using cannabis. She had a positive toxicology for alcohol and cannabinoids. She was noncompliant with antihypertensive medications. She also had elevated aspartate transaminase (AST)/ alanine aminotransferase (ALT) of 200/108. She was put on an Ativan taper and was transferred back to inpatient rehabilitation 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. 

In this case this patient had been drinking large amounts of alcohol daily including 1 bottle of wine or vodka daily for years. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated in a less restrictive treatment setting as she continued to use large amounts of alcohol daily despite significant medical problems. She reportedly had significant QTc of 547 and low magnesium of 1.2 and elevated AST/ALT of 200/108, neuropathy, and hypertension. She was too at risk for life threatening cardiac issues and could not safely be treated in a less restrictive setting other than an inpatient acute hospital setting. She also was at risk for severe withdrawal, complicated, or life-threatening withdrawal due to her large amount of daily alcohol use and required and received detoxification medication and Ativan. 

It was reported that she had withdrawal symptoms and also took Ativan 2 mg (milligrams) three times per day (TID) for detoxification treatment, then Ativan 2 mg two times per day (BID) for detoxification treatment, then Ativan 2 mg daily for detoxification treatment. She had controlled withdrawal and had Ativan prescribed PRN (as needed) and was discharged and transferred back to the inpatient rehabilitation setting for further alcohol rehabilitation treatment. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so she required the entire time in this hospital setting for detoxification treatment. Also, she was on telemetry for cardiac monitoring as she was considered a high medical risk due to her significantly prolonged QTC and low magnesium. She reportedly could not stop alcohol use without being in a 24-hour setting and due to her detoxification needs and acute medical issues, she required inpatient hospital treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment. 

The health care plan did not act reasonably, with sound clinical judgment, or in the best interests of the patient.  

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