Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a female patient with a history of hypertension and diabetes and seizures; possibly related to alcohol. The patient presented to the Emergency Department (ED) with complaints of headaches, photophobia, phonophobia and nausea. The patient reported that she had recently been hospitalized due to alcohol withdrawal and electrolyte abnormalities. The patient was noted to have tremors in both hands; the patient reported it to be a chronic. The patient had Clinical Institute Withdrawal Assessment (CIWA) scores of 4 and 3.  Laboratory work up was performed that revealed anion gap acidosis due to starvation and ketosis. The patient received intravenous (IV) fluids, IV Reglan, IV Zofran, Toradol, magnesium, Librium and Ativan. The patient was medically stabilized and discharged home. 

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 comorbid medical conditions (hypertension, diabetes) complicating the management of this patient's alcohol withdrawal, and the patient had past history of seizures associated with alcohol. The patient was also noted to have recent detoxification for alcohol withdrawal with electrolyte abnormalities. The patient was at a high risk for delirium tremens without acute inpatient level of care and detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24 hour treatment as the patient could not have safely and effectively been treated for detoxification in a less restrictive setting as she continued to use alcohol, and had CIWA scores of 4 and 3 that required intravenous detoxification medication to modify alcohol withdrawal symptoms. The risk of delirium tremens can occur 3-4 days after alcohol use. The patient's past medical history of seizures associated with alcohol, as well as her recent detoxification hospitalization for alcohol withdrawal indicated that this patient was a high risk for relapse and life-threatening seizures, such as delirium tremens. 

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

The carrier's denial of coverage for the inpatient admission is reversed. The medical necessity is substantiated.