Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol abuse and withdrawal. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This patient was admitted to inpatient hospital treatment for reports of tremors including uncontrollable shakes, as well as abdominal pain, agitation, headache, and a medical issue including low potassium and magnesium. He went on a drinking binge of 7 shots per day of vodka for the past 2 weeks. He had hyperglycemia, thrombocytopenia, hypertension, asthma, elevated liver function tests (LFT's), alcohol hepatitis, alcohol esophagitis, and alcohol gastritis. He was given Ativan for detoxification treatment, intravenous (IV) fluids, potassium chloride (KCl) and magnesium (Mg) supplementation. His discharge diagnosis was alcohol abuse and withdrawal. 
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he did not require 24-hour hospital treatment and they recommended a less restrictive level of care such as observational level of care. 
  
The medical records provided enough specific evidence to support that he required 24-hour 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 (DT's) 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 United States 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 DT's, or if one does not have the capacity for informed consent. In this case this patient had active alcohol withdrawal symptoms after going on a 2-week binge of drinking. He also had several comorbid medical conditions including low potassium and magnesium, alcohol hepatitis, alcohol esophagitis, alcohol gastritis, hyperglycemia, thrombocytopenia, hypertension, asthma, and elevated LFT's. 

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 continued to use large amounts of alcohol daily and had active withdrawal symptoms, and he required and received detoxification medication (Ativan) to modify withdrawal from alcohol and more severe withdrawal, complicated or life threatening withdrawal such as DT's. The risk of DT's 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 medical problems due to alcohol use, so he was considered in need of 24-hour inpatient hospital treatment for detoxification. 

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.