Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Admission. 

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

This male patient was admitted to this inpatient hospital after having a syncope episode in the context of alcohol use. He reportedly was drinking alcohol daily including 6 beers per day, and he reportedly slumped and lost consciousness. The primary diagnosis was alcohol withdrawal, and he was treated with 2 detoxification medications including Librium and Ativan. He had low sodium of 120, high creatine kinase (CK) of 456, high aspartate aminotransferase (AST) of 132, high alanine transaminase (ALT) of 53, and had an abnormal electrocardiogram (EKG) with nonspecific ST (interval on EKG [electrocardiogram]) wave abnormalities. He also had gastroesophageal reflux disease (GERD) and Vitamin D deficiency. He reportedly was also using cannabis. The patient also had intravenous (IV) hydration, thiamine, and folic acid. There was consideration for alcohol withdrawal seizures verses cardiogenic syncope verses neurogenic syncope with acute hyponatremia due to alcohol use. He was 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. 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. 

In this case, the patient had acute medical issues complicating the management of withdrawal and required treatment in a hospital, as he had a syncope episode in the context of drinking alcohol, so alcohol withdrawal seizure was being considered. He had very low sodium of 120 and reportedly had lost consciousness. He had EKG abnormalities. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to drink alcohol daily and he reportedly was prescribed 2 detoxification medications including intravenous (IV) Ativan and Librium to prevent severe, complicated, or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at high risk for delirium tremens due to his alcohol use daily. He also had active medical problems requiring hospital treatment including low sodium, abnormal EKG, and was prescribed 2 detoxification medications. There was consideration for alcohol withdrawal seizure verses cardiogenic syncope verses neurogenic syncope with acute hyponatremia due to alcohol use so this treatment in this hospital, as it was unsafe for him to be treated in a less restrictive setting then, as he reportedly lost consciousness.  He did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment, and it was considered unsafe for him to be treated for detoxification management in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting. 

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 inpatient admission is overturned. Medical Necessity is substantiated.