Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable abdominal pain with nausea and vomiting. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This male patient was admitted to the hospital due to abdominal pain, nausea, vomiting, and difficulty keeping fluids down. He had weight loss, and there was suspicion of self-induced vomiting. He did not drink alcohol regularly but drank 4 shots of liquor 4 days prior to admission. He reported using cannabis occasionally. He was discharged from another emergency room one day prior with a similar presentation. His primary diagnosis was intractable abdominal pain. His potassium level was 3.3. He was hydrated with intravenous (IV) fluids and given IV medications.  The patient's symptoms improved after initial treatment. He left the following day against medical advice (AMA). 
  
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 did not have reports of active alcohol withdrawal symptoms, past complicated withdrawal such as alcohol withdrawal seizures or delirium tremens, and there was no reported history of chronic daily alcohol use. 

The medical records stated that the patient did not use alcohol regularly and had 6 shots of liquor 4 days prior to admission but did not have regular use. It also reported occasional cannabis use. There were no reports of (Clinical Institute Withdrawal Assessment) CIWA protocol or detoxification medications given, and it was reported that there was suspicion by his mother that he was self-inducing vomiting. The patient had a primary diagnosis of intractable abdominal pain with nausea and vomiting, but he reportedly had stable vital signs and no reports of alcohol withdrawal or the need for alcohol withdrawal detoxification treatment. There were no reports of acute psychiatric symptoms requiring inpatient hospital treatment, as there were no reports of suicidal or homicidal ideation, intent or plan, hallucinations, delusional or disorganized thinking, aggressive or self-injurious behavior, substance or alcohol withdrawal symptoms that would have required inpatient hospital treatment then, manic or major depressive episodes, inability to adequately care for basic needs, or evidence that he was considered an imminent danger to self or others then.  He reportedly was being treated for abdominal pain with IV fluids and antiemetics. There were no reports of specific identifiable or quantifiable treatment objectives or goals that could only be achieved in a 24-hour inpatient psychiatric or alcohol detoxification hospital. As a result, the recommendation is to uphold the previous decision and deny coverage for inpatient hospital treatment. It appeared that the health care plan acted reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.