Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal.
Treatment is inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This adult female was admitted to this inpatient medical hospital for alcohol detoxification treatment due to alcohol withdrawal symptoms. She reportedly had nausea, vomiting, sweats, tremors, an elevated heart rate of 100-105 bpm (beats per minute), elevated blood pressure of 193/133 mmHg (millimeters of mercury), an elevated respiratory rate of 20 bpm, anxiety, sleeping problems, muscle cramps, anorexia, tactile and auditory disturbances, and she had Clinical Institute Withdrawal for Alcohol (CIWA) score of 16. She reportedly was drinking 12 beers per day with the last drink the day prior to admission. She also reportedly had low platelets, low sodium and low chloride, elevated thyroid stimulating hormone (TSH), and transaminitis. She reportedly had past inpatient treatment. She reportedly had diagnoses of severe Alcohol Use Disorder and Opioid Use Disorder. She received 5 mg (milligrams) of IV (intravenous) Ativan the first day and 260 mg of IV Phenobarbital and 97.2 mg of oral Phenobarbital and was put on seizure precautions. She still had alcohol withdrawal symptoms including a CIWA of 4 with anxiety and headache and her blood pressure was 187/132 mmHg. She received 3 doses of Phenobarbital 97.2 mg for detoxification and received Clonidine 0.1 mg. She also received 2 doses of Phenobarbital 97.2 mg prior to discharge.
 
The medical records provided enough specific evidence to support an inpatient level of care. 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 conditions 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 nausea, vomiting, sweats, tremors, elevated heart rate, elevated blood pressure and respiratory rate, anxiety, sleeping problems, muscle cramps, anorexia, tactile and auditory disturbances, and she had CIWA of 16. She reportedly was drinking a large amount of alcohol per day and had a diagnosis of severe alcohol use disorder. She also had comorbid medical conditions complicating the management of withdrawal and she had low platelets, low sodium, and low chloride, elevated TSH (thyroid stimulating hormone), and transaminitis in addition to her uncontrolled hypertension. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission services is substantiated.