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 was admitted to this inpatient hospital to the telemetry unit, due to alcohol detoxification treatment. He presented with alcohol withdrawal symptoms including tremors, sweats, elevated heart rate of 101, elevated blood pressure of 153/100, abdominal pain, dizziness, shortness of breath, sleeping problems, elevated respiratory rate, and had a Clinical Institute Withdrawal Assessment (CIWA) score of 12. He reportedly was drinking a half bottle of vodka per day for the past 3-4 months. It was reported that he had suicidal and homicidal ideation and depression. He had diagnoses of Alcohol Use Disorder and Major Depressive Disorder and gastroesophageal reflux disease (GERD). He reportedly lived with his mother. He was seen by the psychiatric consultant, who recommended Mirtazepine for depression and anxiety and also recommended alcohol detoxification and rehabilitation treatment. The patient was given Lorazepam 2 mg (milligrams) twice and then Librium 50 mg twice and put on a Librium taper for alcohol detoxification treatment prior to discharge.
   
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 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 reports of active alcohol withdrawal symptoms. The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at risk for severe, complicated, and life-threatening withdrawal and in need of 24-hour hospital treatment. 

He did require 24-hour inpatient 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. He also had presented with depressive symptoms and suicidal and homicidal thoughts at admission, and the psychiatry consultant recommended Mirtazepine for depression and anxiety and recommended detoxification and rehabilitation treatment for alcohol use. He was considered a high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment and could not stop use on his own. 

Based on the above, the insurer's denial must be overturned. 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 Inpatient Admission is substantiated.