Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.

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

This adult male reportedly was admitted to this inpatient hospitalization for alcohol detoxification treatment. He reportedly had alcohol withdrawal symptoms including elevated heart rate and blood pressure, tremors, sweats, abdominal pain, anxiety, and chest palpitations. He reportedly drank 2 12 pints of hard liquor and smoked cannabis. He reportedly had a recent inpatient treatment episode for detoxification treatment one month prior and left against medical advice (AMA) after 2 days. He reportedly had elevated White Blood Cells (WBC) and liver function tests (LFT's). He reportedly was put on a Clinical Institute Withdrawal Assessment (CIWA) protocol and prescribed Librium for alcohol withdrawal. He also reportedly had depressive and anxiety symptoms and took Sertraline, Quetiapine, and Hydroxyzine. He reportedly left AMA again.
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that there were no significant signs of alcohol withdrawal along with high-risk history such as seizures or severe heart disease, severe alcohol withdrawal such as heart rate over 120 or temperature over 101 that did not respond to observational treatment, signs of complicated opioid withdrawal with severe vomiting/diarrhea, or severe blood work abnormality that did not respond to emergency or observational level of care. The insurer recommended a less restrictive level of care.
 
The medical records provided enough specific evidence to support that he required this level of care. 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. Also, 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 active alcohol withdrawal symptoms including elevated heart rate and blood pressure, tremors, sweats, abdominal pain, anxiety, and chest palpitations and had a large, reported amount of alcohol use as he reportedly drank 2 12 pints of liquor.  He also had reported medical issues including elevated WBC and LFT's. 

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 an inpatient admission is substantiated.