Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to the hospital for alcohol detoxification treatment as the patient reportedly had alcohol withdrawal symptoms including dry heave vomiting, shaking, agitation, elevated heart rate as high as 114, elevated blood pressure as high as 180/90, tactile disturbance including burning, itching, and feeling pins, and hallucinations. The patient reportedly had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) as high as 24 and had reports of a past alcohol withdrawal seizure. The patient reportedly was drinking up to 12 beers per day and not eating and had hyponatremia. The patient reportedly was put on telemetry monitoring and a Librium protocol and given Librium for detoxification treatment. The patient reportedly still had alcohol withdrawal symptoms including agitation, vomiting, and had a CIWA of 11. The patient reportedly was trying to leave and refused Librium detoxification treatment. The patient reportedly was given Ativan. 

The insurer denied coverage for inpatient hospital treatment for alcohol detoxification from as not medically necessary treatment then. They stated that the patient was not unstable, had no signs of alcohol withdrawal or high risk history, and they recommended a less restrictive level of care such as observational level of care.

This patient was a high-risk patient with active significant withdrawal symptoms including dry heave vomiting, shaking, agitation, elevated heart rate as high as 114, elevated blood pressure as high as 180/90, tactile disturbance including burning, itching, and feeling pins, and hallucinations. The patient reportedly had a CIWA as high as 24 and had reports of a past alcohol withdrawal seizure which requires inpatient detoxification treatment. The American Psychological 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. This was the case with this patient as the patient used a large amount of alcohol daily with medical issues including hyponatremia due to their large amount of fluid intake. The patient also had a past alcohol withdrawal seizure reported and was in significant alcohol withdrawal including a CIWA of 24. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24 hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as they continued to drink large amount of alcohol and had active withdrawal symptoms including dry heave vomiting, shaking, agitation, elevated heart rate as high as 114, elevated blood pressure as high as 180/90, tactile disturbance including burning, itching, and feeling pins, and hallucinations with a CIWA of 24. The patient also had a past alcohol withdrawal seizure which put the patient at high medical risk, and the patient received and required detoxification medication including Librium and Ativan. 

Based on the above, the insurer's denial must be reversed. 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 is substantiated.