Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.  

This male patient has a medical history of hepatitis, elevated liver function tests (LFT's), lactic acidosis, hyponatremia with dehydration, and psoriasis. He reportedly lived alone.  This patient was admitted to the hospital for alcohol detoxification treatment. He had withdrawal symptoms including nausea, multiple episodes of vomiting, epigastric pain, hand tremors, increased heart rate, inability for oral intake with weight loss, anxiety, and agitation. He was drinking 1 bottle of vodka per day. He was given 2 doses of intravenous (IV) Ativan for detoxification and then put on a standing Librium protocol. He had IV fluids, Reglan, and Pepcid.  He had withdrawal symptoms throughout the hospital stay.  He was discharged 4 days later.

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.  In this case, this patient had been drinking large amounts of alcohol daily including up to 1 bottle of vodka per day and had active withdrawal symptoms requiring detoxification medications.  He also had multiple medical issues including hepatitis, elevated liver function tests (LFT's), lactic acidosis, hyponatremia with dehydration, and psoriasis with alcohol withdrawal symptoms as he reportedly had nausea, multiple episodes of vomiting, epigastric pain, hand tremors, increased heart rate, inability for oral intake with weight loss, anxiety, and agitation.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) this patient did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use increased amounts of alcohol despite medical issues and active withdrawal symptoms. He required and needed detoxification medications to modify withdrawal and needed 24 hour treatment as he was at risk for worsened withdrawal symptoms including severe and life threatening withdrawal symptoms.  It was reported that he had detoxification medication (Lorazepam) with 2 IV doses on admission and then a Librium standing protocol.  He had increased withdrawal symptoms including tremors and dilated pupils requiring detoxification treatment.  He had continued withdrawal symptoms including more severe tremors, anxiety, and agitation requiring detoxification treatment.  It was unlikely that he would remain abstinent while still having withdrawal symptoms so he required the time in this inpatient hospital detoxification treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24 hour setting, and also to prevent possible life threatening withdrawal symptoms.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this hospital.

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

The medical necessity for inpatient hospital admission is substantiated. The carrier's denial of coverage for the inpatient hospital admission is overturned.