Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol withdrawal verses thyroid medical issues.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This patient was admitted for alcohol withdrawal verses thyroid medical issues, as he had elevated heart rate of 111, palpitations, diaphoresis, nausea, tremors, anxiety, and had other medical issues including elevated T(thyroid)3 and free T4 and low thyroid stimulating hormone (TSH), low magnesium (Mg), folate and B12 deficiency, leukopenia, transaminitis, and had been drinking 2 pints of liquor per day with use the day of admission. He had hepatitis, Graves disease, and structural heart disease. He reportedly had an endocrine consultant and was given Librium and put on a Clinical Institute of Withdrawal Assessment (CIWA) protocol for withdrawal. 
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that the patient did not require 24-hour hospital treatment then. They recommended a less restrictive level of care such as observational or ambulatory level of care then.
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment and the medical records provided enough specific evidence to support that he required inpatient hospital treatment then. In this case this patient had several comorbid medical conditions complicating the management of withdrawal including thyroid issues as he had elevated T3 and free T4 and low TSH, low Mg, folate and B12 deficiency, leukopenia, transaminitis, and he reportedly had a medical history significant for multiple serious medical conditions, hepatitis, Graves disease, and structural heart disease. He reportedly had elevated heart rate of 111, palpitations, diaphoresis, nausea, tremors, and anxiety which was consistent with alcohol withdrawal or elevated thyroid. He reportedly was drinking 2 pints of liquor daily with last use the day of admission, so he was at risk for severe, complicated, or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at risk for delirium tremens (DT) due to his large amount of alcohol use daily with these symptoms mentioned and an active CIWA score. He reportedly was put on a CIWA protocol and given Librium for detoxification treatment. He also had multiple medical problems which put him at medical risk and did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment. It was considered unsafe for him to be treated for alcohol detoxification and medical treatment in a less restrictive level of care then and also unsafe for him to be treated medically outside of a hospital setting due to his significant medical history and other medical issues. He was considered at risk for worsened medical issues and worsened withdrawal including more severe, complicated, or even life-threatening withdrawal due to his heavy daily alcohol use. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment.

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 inpatient hospital admission is substantiated.