Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient is a male was admitted to this inpatient hospital for cellulitis of both legs, hematoma, and deep vein thrombosis (DVT) in his arm, and alcohol detoxification. He had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) score of 9 and was very tremulous, agitated, nauseous, had anxiety, headache, and tactile hallucinations of bugs crawling on him. He was verbally abusive to staff. The patient was drinking 3 liters of alcohol per day. He reportedly was homeless. He had a diagnosis of schizophrenia, gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD). The patient was involved in an altercation prior to admission and fell and was hurt. He was given Ativan 2 mg (milligrams) and put on an Ativan CIWA protocol and taper which concluded. He reportedly was put on 2 intravenous (IV) antibiotics including Cefazolin and Clindamycin for cellulitis and fungal treatment, and also given Lovenox for his DVT. The patient was discharged when his IV antibiotics were completed, and he was given oral antibiotics including Keflex and Eliquis for his DVT. 
    
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 (United States) 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 several comorbid medical conditions complicating the management of withdrawal and he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment. 

He also had significant medical problems including cellulitis and DVT requiring IV antibiotics and Lovenox. He reportedly was homeless with a diagnosis of schizophrenia and was unable to care for his medical needs if not in this 24-hour hospital. He was put on a CIWA protocol with an Ativan taper for alcohol detoxification which was complete but still required hospitalization for further IV antibiotic treatment of his cellulitis. He was at risk of sepsis if this were not treated and he likely would have been noncompliant as he was homeless and drinking 3 liters of alcohol daily and had a diagnosis of schizophrenia. 

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 in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues requiring hospital treatment. He also was homeless and lacked supports and coping skills and the ability to care for his acute medical needs. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

The health care plan did not act reasonably, with sound medical judgment, or in the best interests of the patient. 

The insurer's denial of coverage for inpatient admission overturned. Medical Necessity is substantiated.