Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial was overturned. 

This is a male patient with a history of schizophrenia and depression. He was admitted to the hospital for inpatient management of his alcohol withdrawal symptoms that included abdominal pain, nausea, vomiting, tremors, chills, and headache. He had a Clinical Institute Withdrawal Assessment (CIWA) for an Alcohol score of 11. The patient reported drinking 2 pints of vodka per day. The patient's medical treatment included intravenous fluids, a proton pump inhibitor, Serax taper, and Ativan.  It was noted that the patient had severe pruritus due to lice/scabies. He was consulted by Dermatology and empirically treated for lice and scabies with whole-body permethrin. It was also reported that the patient had alcohol-induced thrombocytopenia. The patient was stabilized and discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 a comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. In this case, this patient could not have been safely treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to his large amount of daily alcohol use. The patient also had comorbid medical issues, such as colitis and alcohol-induced thrombocytopenia that could complicate the management of his alcohol withdrawal.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated in an outpatient detoxification settings as he continued to use large amounts of alcohol despite medical issues. He required and needed detoxification medication to modify his withdrawal symptoms and to prevent more severe withdrawal symptoms. Also, at the time of hospital presentation, the patient had active withdrawal symptoms that included nausea and vomiting, tremors, chills, headache, and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 11. The patient required as needed Ativan and a Serax 4-day taper to treat his alcohol withdrawal and detoxification needs.  The patient needed to be in the inpatient hospital setting for detoxification treatment as he was at risk for life-threatening withdrawal.  Studies indicate that the risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, so this patient required inpatient detoxification protocol treatment.  

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.