Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient was admitted to inpatient hospital treatment due to alcohol withdrawal symptoms and atrial fibrillation with elevated heart rate in the 160's. He reportedly had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 9 on admission and had withdrawal symptoms including tremors, elevated heart rate, increased agitation, anxiety, and weakness. He reportedly was initially refusing to answer questions. He reportedly had elevated liver function tests and elevated lipase, and anemia. He reportedly was drinking up to 5 pints of vodka per day for years and also had used cocaine and had a significant past history of heroin use. He reportedly had multiple past hospitalizations and a past inpatient rehabilitation treatment. He reportedly was given 2 detoxification medications including 5 Librium 25 milligram (mg) doses and was given Ativan IV (intravenous) 1 mg and 2 mg and then put on an Ativan taper with day one Ativan 2 mg every (q) 6 hours, day 2 Ativan 2 mg q 8 hours, day 3 Ativan 1 mg q 8 hours, and then day 4 Ativan 1 mg q 12 hours. He reportedly was transferred from internal medicine floor to cardiology due to rapid heart rate atrial fibrillation. He reportedly left against medical advice (AMA).
    
According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use very large amounts of alcohol daily,  had active withdrawal symptoms including CIWA of 9, tremors, agitation, and he required and received detoxification medications (Lorazepam and Librium) to modify withdrawal from alcohol and prevent more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens (DTs) can occur 3-4 days after alcohol use so he was considered at high risk for DT's due to his large amount of alcohol use daily with active withdrawal symptoms. He also had significant medical problems including atrial fibrillation with elevated heart rate in the 160's, elevated LFT's (Liver Function Test) and elevated lipase, and anemia. He reportedly had a significant amount of detoxification medication including 5 Librium 25 mg doses and was given Ativan IV 1 mg and 2 mg and then put on an Ativan taper with day one Ativan 2 mg q 6 hours, day 2 Ativan 2 mg q 8 hours, day 3 Ativan 1 mg q 8 hours, and then day 4 Ativan 1 mg q 12 hours. He reportedly left AMA on day 4. He had cardiac issues and was transferred even from the medical floor to the telemetry cardiology floor. He did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues and active withdrawal from alcohol requiring hospital treatment. 

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

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