Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 
 
This adult was admitted to this inpatient hospital due to alcohol withdrawal symptoms including elevated heart rate of 110, tremors, anxiety, and he had a reported Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA) of 9, and he reported chest pain 4 out of 10. He had a significant past medical history of myocardial infarction and bypass surgery and congestive heart failure (CHF). He had acute renal injury and thrombocytopenia. He reportedly drank 8 bottles of whiskey over the past 6 days after 4 months of abstinence. He was given Librium and put on a Librium protocol for alcohol detoxification treatment. He also was on telemetry monitoring, seizure precautions, an antiplatelet agent, and given B12 and folate. 

The medical records given for review provided enough specific evidence to support that he required an inpatient level of care. 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. 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 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 elevated heart rate of 110, tremors, anxiety, and he had a reported CIWA of 9, and he had comorbid medical issues including reporting chest pain and reportedly had a significant past medical history of myocardial infarction and bypass surgery and CHF, and he also reportedly had acute renal injury and thrombocytopenia. He reportedly drank 8 bottles of whiskey over the past 6 days which is considered a large amount of alcohol use and this put him at risk for severe withdrawal, complicated, and life threatening withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment (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 for the past 6 days and received detoxification medication, Librium, to modify withdrawal from alcohol and prevent more complicated or life-threatening withdrawal such as delirium tremens. 

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 hospital admission is substantiated.