Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Ideations

Treatment: Inpatient Hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male was admitted to inpatient hospital due to being unresponsive in the Emergency Department and he was obtunded. He drank large amounts of alcohol with an alcohol level as high as 421. His sister heard him make suicidal statements and he had 3 past suicide attempts. He had subsequent severe withdrawal symptoms including Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores as high as 21 and he required numerous doses of intravenous Lorazepam for detoxification treatment. He had a recent discharge from the hospital and required intubation and this was 1 week prior to admission. He had been drinking 1-2 liters of vodka per day and had a positive toxicology for benzodiazepines and barbiturates. He had multiple past inpatient admissions for detoxification and rehabilitation treatment. He also had multiple past psychiatric hospitalizations. He was recently homeless. He also reportedly had hepatitis C. He lost his job several months prior to admission. He was monitored with telemetry, had intravenous fluids and intravenous Naloxone and still had no gag reflex, had intravenous Lorazepam and oral Librium, and intramuscular Haldol. He was on suicide precautions and close observation. He was considered too medically unstable for a psychiatric hospitalization. He was discharged as he requested to leave.

The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide. Suicide attempts are the single most reliable indicator of suicide. In this case this patient had multiple past suicide attempts so he was considered a high suicide risk with this history and current depression and recent suicidal thoughts reported by his sister. He was intubated at his most recent hospitalization 1 week prior to this admission. CIWA score was between 10-20, which is high and put him at risk for life threatening withdrawal including delirium tremens and withdrawal seizures. He received intravenous Lorazepam 1 milligrams 4 times, 2 milligrams 3 times, 4 milligrams once, and intravenous Phenobarbital, as well as intravenous Magnesium, and was put on Librium 75 milligrams orally every 4 hours, and also took Seroquel for agitation. Other notes that he received multiple intravenous Lorazepam including 2 milligrams 3 times, 3 milligrams 4 times, and 4 milligrams once and had a CIWA of 17, was pacing and agitated, and he wanted a razor and attempted to drink hand sanitizer. Notes reported that his CIWA was as high as 21 and he required intravenous Lorazepam 4 times, was restless, agitated, verbally aggressive, and threatened to throw a chair, and he required 1:1 close observation and suicide precautions, and also was prescribed Haldol intramuscular. Notes reported that he required intravenous Lorazepam 2 milligrams 3 times and intramuscular Haldol twice, and was still agitated, anxious, and restless. Other notes reported that he requested discharge and had no reports of suicidal thoughts, severe agitation, or severe withdrawal. He did require 24 hour 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 as he had severe withdrawal and required multiple doses of intravenous Lorazepam during the denial period and also was depressed and a suicide risk due to multiple past attempts and reports of suicidal thoughts and lacked support as he was homeless. 

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

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.