Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal.

Treatment is an inpatient admission.

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

This patient was admitted to the hospital complaining of worsened shortness of breath, chest tightness, and reportedly had fever, chills, fecal incontinence, and urinary obstruction and recently left a skilled nursing facility against medical advice (AMA) and had worsening difficulty with self-care as he was homeless and drinking alcohol and had a blood alcohol level (BAL) of 284. He reportedly had withdrawal symptoms including tremors, tongue fasciculations, and anxiety and had past reported alcohol withdrawal seizures. He had metastatic prostate cancer, and his ECG (electrocardiogram) revealed an AV (Atrioventricular) block. He reportedly had detoxification medication including IV (intravenous) Valium and then was prescribed Librium and had CIWA (Clinical Institute Withdrawal Assessment Alcohol) monitoring, IV thiamine and took Gabapentin as he reported severe pain. He was seen by hematology oncology and started on medication for his cancer. He was discharged administratively after becoming aggressive to staff. 
    
The medical records provided enough specific evidence to support that the patient required this level of care. The APA (American Psychiatric Association) 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. 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 comorbid medical conditions complicating the management of withdrawal as he had metastatic prostate cancer, current alcohol withdrawal symptoms and past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment. Notes reported diffuse body pain, slurred speech, tongue fasciculations, tremors and he took IV Valium for detoxification and was prescribed Librium for detoxification. There also was concern medically for alcohol cardiomyopathy as he had chest tightness and worsened shortness of breath. 

He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care. 

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

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