Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

This male was admitted to the hospital for detoxification treatment due to alcohol withdrawal symptoms. He was on telemetry initially as he had bradycardia with heart rate ranging from 48-65. He had alcohol withdrawal symptoms including tremors, nausea and vomiting, agitation, anxiety, moist palms, shaking, and also had chest tightness, dizziness, dyspnea, and arthralgia and had a rising Clinical Institute Withdrawal Assessment for Alcohol (CIWA) as high as 16. He had medical issues due to alcohol use including elevated liver function tests (LFT's) and thrombocytopenia. He was put on a Lorazepam taper CIWA protocol and given Lorazepam 2 milligrams (mg) intramuscular (IM) and 1 mg by mouth (po) on the day of admission and was given Lorazepam through discharge. He was homeless and had psychiatric diagnoses and was taking multiple psychotropic medications. He took Lorazepam 1 mg 3 times per day the day prior to discharge and then Lorazepam 0.5 mg twice per day on the day of discharge.
    
The medical records provided enough specific evidence to support the need for inpatient hospital 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. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had active alcohol withdrawal symptoms including tremors, nausea and vomiting, agitation, anxiety, moist palms, shaking, chest tightness, dizziness, dyspnea, arthralgia and had a rising CIWA and was at risk for more severe, complicated, life-threatening withdrawals. He also had several comorbid medical conditions due to alcohol use including elevated LFT's and thrombocytopenia and also had bradycardia requiring telemetry monitoring. The risk of delirium tremens can occur 4 days after alcohol use so he was considered at risk and in need of 24-hour inpatient hospital detoxification treatment. 

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 for detoxification in a less restrictive setting as he had active withdrawal symptoms including CIWA of 16 and was shaky with tremors, nausea and vomiting, agitation, anxiety, and sweaty palms and required and received detoxification medication (Lorazepam) to modify withdrawal from alcohol and more severe withdrawal, complicated or life-threatening withdrawal such as delirium tremens. 

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 inpatient admission is overturned. Medical Necessity is substantiated.