Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this hospital on the medical floor due to alcohol withdrawal symptoms including tremors, tongue fasciculation, vomiting, diarrhea, and abdominal pain and had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 13. The patient reportedly was drinking up to 10 beers per day 3-4 times per week. The patient reportedly had a history of gastritis. The patient reportedly had multiple emergency room (ER) visits for similar issues. It was reported that there was concern that they had acute alcohol withdrawal in the setting of colitis. The patient reportedly was prescribed Librium, Lorazepam, intravenous (IV) fluids, IV antibiotics, and ondansetron. The patient reportedly left  against medical advice (AMA) despite the recommendation to stay and complete the detoxification treatment. 
 
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 or current 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 or current withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had reports of current and active alcohol withdrawal including tremors, tongue fasciculation, vomiting, diarrhea, and abdominal pain and had a CIWA of 13. The patient also had a history of gastritis and there was concern for colitis with acute alcohol withdrawal, so she required inpatient hospital treatment then. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient did require 24 hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as they continued to use large amounts of alcohol including up to 10 beers per day 3-4 times per week and had a history of multiple ER visits for similar issues but still could not stop alcohol use which put the patient at risk of severe, complicated, and life threatening withdrawal such as delirium tremens. The patient did require 24-hour inpatient medical hospital treatment for detoxification treatment as the patient reportedly was prescribed Librium and Lorazepam for detoxification treatment and also was treated for medical issues including taking IV antibiotics, IV fluids, and ondansetron. 

Based on the above, the insurer's denial must be reversed. 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 the inpatient admission is substantiated.