Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Withdrawal symptoms

Treatment: Inpatient admission

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

This is a male patient who was admitted for inpatient alcohol detoxification, gastrointestinal (GI) bleed, and chest pain. The patient had active withdrawal symptoms including tremors, nausea and vomiting, and had past history of withdrawal seizures. The patient also reported hematemesis, and had new inverted T waves on his electrocardiogram (EKG). The patient's urine analysis showed urobilinogen, and he had metabolic acidosis. The patient was drinking 1 pint of vodka per day and using cocaine. The patient's urine toxicology was positive for alcohol and benzodiazepines. The patient's upper GI endoscopy revealed esophagitis, gastritis, and duodenitis. The patient was treated and discharged with a scheduled date for inpatient rehabilitation for alcohol rehabilitation.

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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

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 several comorbid medical conditions complicating the management of withdrawal and he had past reported alcohol withdrawal seizures which require inpatient medical detoxification treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily, required and received detoxification medication (Ativan) to modify withdrawal from alcohol and prevent another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens. The patient was also homeless and lacked support and coping skills. Considering this clinical presentation as well as this patient's history of withdrawal seizures, inpatient admission was medically necessary for this patient's detoxification treatment.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial should be reversed.