Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal. 
Treatment: Inpatient Hospital. 

The insurer denied coverage for inpatient hospital. The denial is overturned. 
 
This adult patient reportedly was admitted to this inpatient hospital for alcohol detoxification due to alcohol withdrawal symptoms, including vomiting, sweats, tremors, increased heart rate, elevated blood pressure of 148/76, chills, and had a Clinical Institute Withdrawal Alcohol (CIWA) score of 14. The patient reportedly also had abnormal labs, including low potassium (K) of 2.7, low magnesium, elevated aspartate transferase (AST) of 51, alanine transaminase (ALT) of 57, and high anion gap metabolic acidosis. It was reported that the patient was drinking 3-4 shots of vodka per day, with the last drink one day before admission. The patient reportedly still had reports of alcohol withdrawal symptoms after admission, as the patient reportedly had a CIWA score of 10 and still had shakes and nausea as well as hand tremors. Their platelets dropped from 187 to 125, their potassium was still low at 3.1, and they required 4.5 milligrams (mg) of Ativan and intravenous (IV) Zofran twice and then needed an additional 2.5 mg of Ativan IV and IV Zofran again and had continued Phenobarbital every (q) 8 hours. The patient reportedly had Phenobarbital 64.8 mg q 8 hours and IV Ativan on admission. The patient still reportedly received a taper dose of Phenobarbital 32.4 mg but no longer scored on CIWA and was discharged that day. 

The medical records provided enough specific evidence to support that the patient required this inpatient 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, 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 was unlikely that the patient would remain abstinent while having withdrawal symptoms, so the patient required the time in this treatment setting to stop withdrawals and decrease the chance that she would relapse again when not in this 24-hour setting and also to prevent possible life-threatening withdrawal symptoms. The risk of life-complicated withdrawal, such as delirium tremens, can occur four days after alcohol use, so the patient requires the entire time in this hospital. The patient also did not have the coping skills to maintain abstinence and receive treatment in a less restrictive setting other than this inpatient detoxification hospital treatment, as the patient could not stop alcohol use outside of a 24-hour hospital setting. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance hospital treatment for alcohol detoxification treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for the inpatient hospital admission is substantiated.