Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal.

Treatment inpatient emergency admission.

The insurer denied coverage for inpatient emergency admission.

The denial is overturned.

This female was admitted to this inpatient emergency hospital setting due to alcohol withdrawal. She had active withdrawal symptoms including nausea and vomiting including bloody vomiting, tremors, shakiness, jitteriness, anxiety, elevated heart rate up to 137, elevated blood pressure of 151/101, elevated respiratory rate, and she had a past reported alcohol withdrawal seizure. The patient had multiple active medical issues including severe hypokalemia with a potassium of 2.5, low magnesium of 1.4, elevated alanine transaminase (ALT) of 189 and elevated alkaline phosphatase (ALP) of 187, alcohol hepatitis, and prolonged QTc (interval on EKG [electrocardiogram]) interval. She reportedly was drinking 2 bottles of whiskey per day and had 4 bottles per day in the past. She reportedly had panic attacks. She was given intravenous (IV) Ativan for detoxification medication, IV fluids, IV thiamine and folic acid, and IV Protonix. The patient continued to have withdrawal symptoms until discharged.
    
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. 

The US (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 delirium tremens, or if one does not have the capacity for informed consent. 

In this case this patient had a past withdrawal seizure and had current active alcohol withdrawal symptoms including nausea and vomiting including bloody vomiting, tremors, shakiness, jitteriness, anxiety, elevated heart rate up to 137, elevated blood pressure of 151/101, and elevated respiratory rate. She also had active acute medical issues requiring treatment including severe hypokalemia with a potassium of 2.5 and low magnesium of 1.4 which both required IV supplementation, and also had elevated ALT of 189 and elevated ALP of 187, alcohol hepatitis, and prolonged QTc (interval on EKG) interval.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated in a less restrictive treatment setting as she continued to use large amounts of alcohol daily despite medical issues and a past withdrawal seizure and she had active alcohol withdrawal symptoms, and she required and needed detoxification medication to modify withdrawal including IV Ativan throughout her hospital stay. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so she required inpatient detoxification treatment in this hospital setting and was at risk for severe, complicated, or life threatening withdrawal including another alcohol withdrawal seizure or delirium tremens, and she was at high risk medically as she had active medical issues putting herself at risk medically and required medical treatment in the hospital as well so she required 24 hour hospital treatment. This was a high-risk patient medically who was drinking large amounts of alcohol daily who required 24-hour hospital treatment. She was considered a high medical risk due to her prolonged QTC and low magnesium as well as severe hypokalemia. She reportedly could not stop alcohol use without being in a 24-hour setting and due to her detoxification needs and acute medical issues, she required inpatient hospital treatment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Inpatient hospital treatment was medically necessary. 

The insurer's denial of coverage for the inpatient emergency admission is overturned. Medical Necessity is substantiated.