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 patient was admitted to due to alcohol withdrawal symptoms and epigastric pain. The patient reportedly had a Clinical Institute Withdrawal Assessment (CIWA) of 18 which increased to 22. The patient presented with alcohol withdrawal symptoms. The patient was recently discharged from the hospital prior to this admission due to alcohol withdrawal. The patient had past inpatient alcohol rehabilitation treatment and preferred no inpatient alcohol rehabilitation treatment after that last hospitalization. The patient was given intravenous (IV) valium and started on a valium protocol for detoxification treatment. The patient also had IV fluids and electrolyte replacement and was started on proton pump inhibitors. The patient continued with withdrawal symptoms until the day of discharge.
 
The insurer denied coverage for inpatient hospital treatment as not medically necessary. They stated that the patient did not have severe withdrawal symptoms warranting inpatient hospital treatment and they recommended a less restrictive level of care.
  
The American Psychiatric Association 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. The 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. 

In this case this patient had reports of moderate alcohol withdrawal symptoms including elevated heart rate of up to 150, elevated blood pressure of 137/96, nausea, vomiting, tremors, anxiety, elevated respiratory rate and the CIWA was as high as 22. According to the Level of Care Determination the patient did require 24-hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting due to continued use of large amounts of alcohol and active withdrawal symptoms. The patient required and received detoxification medication (valium) to manage withdrawal from alcohol and prevent more severe withdrawal, complicated or life-threatening withdrawal such as delirium tremens (DT). The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at high risk for DT's due to her large amount of alcohol use with active withdrawal symptoms. The CIWA increased to 22 and that the patient was in moderate withdrawal, and had elevated WBC (white blood cell count) of 16, low magnesium of 1.5, low phosphorus of 1.7, a carbon dioxide of 20, and anion gap of 18. The patient received 32 milligrams of IV and oral valium. The patient also had electrolyte replacement. The following day the patient had minimal withdrawal symptoms and a CIWA of 2. The abdominal pain and nausea resolved. The patient was continued on the CIWA protocol and IV fluids. The patient reportedly had no further withdrawal symptoms on the day of discharge and was eating and drinking without nausea or abdominal pain. The medical records supported the need for inpatient detoxification treatment, and it was considered unsafe for the patient to be treated for in a less restrictive level of care. 

Based on the above, the insurer's denial must be overturned. 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.