Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This patient was admitted to inpatient hospital care for alcohol detoxification treatment. He reportedly had alcohol withdrawal symptoms including nausea and vomiting, sweats, tremors, headache, agitation, anxiety, elevated heart rate, disorientation to date, and had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) of 11. He was drinking 2 bottles of Hennessy per day and had a history of alcohol use. He reportedly had elevated liver function tests (LFT), hypokalemia, and transaminitis. He was reportedly triggered to use alcohol by social anxiety. He reportedly had several episodes of alcohol withdrawal in the past. He was put on a Librium protocol for alcohol detoxification treatment, intravenous (IV) fluids, IV banana bag, IV Zofran, and had telemetry monitoring and seizure precautions. He reportedly left against medical advice (AMA).
  
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. 

The United States (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 active alcohol withdrawal symptoms including nausea and vomiting, sweats, tremors, headache, agitation, anxiety, elevated heart rate, disorientation to date, and had a CIWA of 11 and was considered at risk for more severe, complicated, and life threatening withdrawal. He also reportedly had comorbid medical conditions complicating the management of withdrawal including elevated LFT, hypokalemia, and transaminitis. 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 use large amounts of alcohol daily including up to 2 bottles of Hennessey per day, and needed detoxification medication (Librium) to modify withdrawal from alcohol. The risk of delirium tremens can occur 3-4 days after alcohol use, so he was considered at risk for this. He reportedly had multiple past alcohol withdrawal episodes and still could not maintain abstinence, so he likely would not have been able to maintain abstinence without being in a 24-hour inpatient hospital setting. He reportedly left AMA prior to completing the detoxification, but still required inpatient detoxification treatment. 

Inpatient hospital treatment was medically necessary. It did not appear that the health care plan acted reasonably or in the best interest of the patient then.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.