Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission. The denial is overturned.

This male was admitted to this inpatient hospital due to alcohol withdrawal symptoms and medical issues. He had altered mental status, agitation, anxious mood, tremors, diaphoresis, elevated heart rate of 105, elevated blood pressure of 155/99, and abdominal pain. He had elevated glucose of 634, elevated liver function tests (LFT's), blood urea nitrogen (BUN) of 4 and creatinine of 0.68. His creatine kinase (CK) was elevated at 690. He stated on admission that he was in withdrawal from alcohol and needed treatment. He reportedly was drinking rum daily. He had a recent hospital admission for alcohol pancreatitis and alcohol withdrawal. He was given Ativan 3 times and put on Librium 3 times per day and a Clinical Institute Withdrawal for Alcohol (CIWA) protocol for detoxification treatment. He had multiple medical issues including diabetes with uncontrolled glucose, hypertension, and recent alcohol pancreatitis. He also was given intravenous (IV) fluids, insulin, vitamin B12/folate, thiamine, magnesium chloride, and Protonix. He was later discharged.
  
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. 

In this case this patient had several comorbid medical conditions complicating the management of withdrawal and had active alcohol withdrawal symptoms including altered mental status, agitation, anxious mood, tremors, diaphoresis, elevated heart rate of 105, elevated blood pressure of 155/99, and abdominal pain. He had medical issues including elevated glucose of 634, elevated LFT's, BUN of 4, creatinine of 0.68, CK elevated at 690, and had hypertension, uncontrolled diabetes with very elevated glucose, and a recent hospital admission for alcohol pancreatitis. He reportedly was drinking rum daily. He was at risk for severe, complicated, and life-threatening withdrawal, so he required inpatient hospital treatment. 

The risk of delirium tremens can occur 3-4 days after alcohol use, and he reportedly was drinking rum daily, so he was considered at risk for delirium tremens due to his alcohol use daily. He also had multiple medical problems putting him at risk medically, so he required inpatient hospital treatment due to these medical issues with active withdrawal. He also had a recent hospital admission for alcohol pancreatitis and alcohol withdrawal, so he was not considered a candidate for a lower level of care. He did require 24-hour medical hospital treatment for alcohol detoxification treatment and medical treatment, and it was considered unsafe for him to be treated in a less restrictive level of care. It was also unsafe for him to be treated medically outside of a hospital setting, due to his acute medical issues and alcohol treatment issues which required hospital treatment. 

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

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