Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient Hospital Admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

This patient was admitted to inpatient hospital care due to intractable vomiting and alcohol withdrawal symptoms with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) as high as 12.  It was reported that she had vomiting, elevated heart rate and blood pressure, dry mucous membranes, tongue fasciculations, horizontal nystagmus, decreased breath sounds, metabolic acidosis and lactic acidosis and also had pancreatitis.  She reportedly was drinking 1.5 pints of vodka per day and had oral intolerance and was unable to tolerate solid foods or liquids.  She reportedly was put on a CIWA protocol with intravenous (IV) Ativan, Pepcid, Zofran, and IV fluids.  She also reportedly had potassium chloride (KCl), Metoprolol, Hydralazine, and Omeprazole. She was discharged a few days later.

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.  

This patient could not safely be treated in a less restrictive detoxification treatment level of care as she was at risk for severe, complicated, and life threatening withdrawal due to large amounts of daily alcohol use including drinking 1.5 pints per day.  She reportedly had active alcohol withdrawal symptoms including intractable vomiting, elevated heart rate and blood pressure, dry mucous membranes, tongue fasciculations, horizontal nystagmus, decreased breath sounds, and had oral intolerance and was unable to tolerate solid foods or liquids.  She also had medical issues including metabolic acidosis and lactic acidosis and also had pancreatitis.  She was considered a medical risk and also at risk for more severe, complicated, and life threatening withdrawal such as delirium, tremens.  She required detoxification treatment in a hospital setting and was put on a CIWA protocol with IV Ativan, Pepcid, Zofran, and IV fluids.  She also reportedly had KCl, Metoprolol, Hydralazine, and Omeprazole.  This could not be done at a less restrictive level of care.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so she required inpatient detoxification protocol treatment and was at risk medically and required 24 hour hospital treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol daily including up to 1.5 pints of vodka daily, used detoxification medication including IV Ativan to modify withdrawal from alcohol and prevent more serious, complicated, and possibly life threatening withdrawal.  She needed 24 hour inpatient hospital detoxification treatment as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting including possible life threatening withdrawal such as delirium tremens.  

It did not appear that the health care plan acted reasonably or in the best interests of the patient.

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