Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

This is the case of a female reportedly admitted to inpatient hospital treatment due to a syncopal episode in which she lost consciousness and passed out and due to detoxification for alcohol withdrawal symptoms. She reportedly had alcohol withdrawal symptoms including tremors, elevated heart rate at 106, diaphoresis, and anxiety, and had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 7. She reportedly typically drank 1 pint of rum/vodka daily and last drank the morning prior to admission. She reportedly had an alcohol level of 28.3. She reportedly stated that her husband left her and she increased her alcohol use. She reportedly was given intravenous (IV) Ativan for withdrawal. She reportedly had continued telemetry. She reportedly also took thiamine and folic acid. She reportedly had continued alcohol detoxification until 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 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 lost consciousness due to a syncopal episode and had alcohol withdrawal symptoms and was considered a high risk medically.  

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 large amounts of alcohol including up to 1 pint per day of rum/vodka, used detoxification medication including both IV Ativan and oral Ativan to modify withdrawal from alcohol and prevent more severe withdrawal, complicated, or life threatening withdrawal. 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. 

On admission she had reports of alcohol withdrawal symptoms including tremors, elevated heart rate at 106, diaphoresis, and anxiety, and had a CIWA of 7. Notes reported that she had Ativan taper for continued withdrawal. Notes reported that she had cardiac monitoring with vitals every 4 hours and had cardiology consultation and took Ativan 1 milligrams (mg) 3 times per day for detoxification treatment. Notes reported that she had a neurology consultation also and had continued alcohol detoxification treatment including Ativan. Notes reported continued detoxification treatment with Ativan though tapered at Ativan 0.5 mg 3 times per day. She reportedly was cleared for discharge.

This patient required 24 hour medical hospital treatment and was considered a high risk patient for more complicated and life threatening withdrawal. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

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