Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This patient was admitted to inpatient medical hospital care after being brought in by ambulance due to dizziness, numbness, vertigo, difficulty walking, and she reportedly had alcohol withdrawal symptoms including tremors, elevated blood pressure of 152/90 and elevated heart rate of 109, headache, and she reportedly was dehydrated. She reportedly was drinking 6 beers per day. She reportedly had head trauma after fighting with someone and getting hit in the face and falling on her head. She reportedly was admitted to the medical floor and put on cardiac monitoring and was given intravenous (IV) fluids, thiamine, folic acid, and Librium for detoxification treatment. She also was being ruled out for a subdural hematoma and alcohol ketoacidosis. She reportedly improved and was 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 Interqual Acute Adult Medical: General Medical Withdrawal Syndrome criteria reports that if one has either Clinical Institute of Withdrawal Assessment (CIWA) 8-14, or blood pressure changes including greater than 150/90, systolic blood pressure greater than 150, or diastolic blood pressure equal or greater than 100, heart rate over 100,  dehydration, or disorientation, hallucinations, myoclonic contractions, seizures, temperature of equal or greater than 101, or protracted vomiting, then criteria are met. In this case this patient had reports of acute alcohol withdrawal symptoms including an elevated heart rate of 109 and elevated blood pressure of 152/90 and had tremors, so she was at risk for more severe, complicated, and even life-threatening withdrawal. Her CIWA was as high as 12. She reportedly was drinking alcohol daily. 

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 for detoxification in a less restrictive setting as she continued to use alcohol, used detoxification medication, Librium, to modify withdrawal from alcohol, and she needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at risk for this. She also had reports of medical issues including head trauma, possible alcohol ketoacidosis, difficulty ambulating, vertigo, and dizziness. The chart notes did support that she could not have safely been treated in a less restrictive setting other than an inpatient hospital treatment then. She required inpatient medical detoxification treatment as she was considered at risk for life threatening withdrawal including delirium tremens due to her alcohol use. 

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient then.

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