Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol abuse

Treatment inpatient hospital admission

The insurer denied coverage inpatient hospital admission

The denial is overturned

This male patient reportedly was admitted to an inpatient hospital due to an alcohol withdrawal seizure and for management of detoxification. He reportedly had withdrawal symptoms including a seizure the morning of admission, tremors, an elevated heart rate, elevated blood pressure, flushing, tongue fasciculations and dehydration. He reportedly had a past alcohol withdrawal seizure. He reportedly was started on IV fluids, thiamine, folic acid, IV (intravenous) Lorazepam detoxification protocol was ordered, and he was on seizure precautions. 

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 MCG (Milliman Care Guidelines) Substance Related Disorder criteria report that one meets criteria if one was withdrawal signs with high risk indicators including one of the following: heart rate over 100, nausea/vomiting, tremors, increased perspiration, or other physical signs of alcohol or sedative withdrawal; elevated risk due to historical or combined factors with one of the following: history of delirium, seizures due to alcohol or sedative/hypnotics, intrinsic seizure disorder, pregnancy, or signs of medical disorders; severe alcohol or sedative withdrawal not manageable at a lower level of care with a heart rate over 120, severe vomiting, grossly visible tremor, temperature greater than 101 Fahrenheit or 38.3 Celsius, or other physical signs; inadequate response to pharmacotherapy in the emergency department (ED) or an appropriate lower level of care or a lower level of care is not feasible or appropriate; 1 of the following: one is judged to be likely to improve with this treatment or likely to deteriorate with this level or care, or the patient is receiving continuing care and needs treatment; 1 of the following: the patient is unwilling to participate voluntarily in treatment and requires involuntary treatment or voluntary treatment is not feasible or there is a need for restraints/seclusion or other involuntary control or nursing care; of if in opioid withdrawal one needs around the clock care with all of the following: vomiting or diarrhea due to opioid withdrawal with marked dehydration or electrolyte abnormalities. He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.

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