Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal symptoms
Treatment: Inpatient Hospital Treatment
The insurer denied coverage for: Inpatient Hospital Treatment
The denial is: Reversed.
This adult reportedly was admitted to this inpatient hospital treatment due to alcohol withdrawal symptoms. The patient had elevated heart rate as high as 136, elevated blood pressure of 164/99, nausea, vomiting via dry heaves, tremors, anxiety, disorientation, and agitation, and had a Clinical Institute Withdrawal Assessment (CIWA) of 10. The patient had labs consistent with alcohol ketoacidosis and had transaminitis due to hepatic steatosis. There were T wave inversions on the electrocardiogram (EKG). It was reported that there was heavy alcohol use by binge drinking over the past 10 days including drinking 250 cubic centimeter (cc) of 40% (percent) liquor per day. The patient had 10 episodes of binging on average per year. The patient had the last drink the day of admission. The blood alcohol level (BAL) was 342. The patient had a past alcohol inpatient detoxification a few years ago. The patient reportedly was given 250 milligram (mg) of Librium and Ativan 4 mg intravenous (IV) for alcohol detoxification treatment. The patient was discharged when considered medically stable.
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he did have medical issues requiring 24-hour hospital treatment. They recommended a less restrictive level of care.
 
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment and the medical records for review did provide enough specific evidence to support that the patient required this 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 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. 
The patient was considered at medical risk for severe, complicated, and life-threatening withdrawal such as delirium tremens (DT's). The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for DT's due to his large amount of alcohol use over the past 10 days during this binge. There were active withdrawal symptoms and medical issues. The patient did require 24-hour inpatient 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. 

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 inpatient admission is substantiated.