Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pancreatitis.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a male patient who presented to the hospital with epigastric pain thought to be a result of pancreatitis due to alcohol use.  The patient reportedly had his last alcoholic beverage one week prior to admission.  An ultrasound of the liver and pancreas was performed that revealed hepatic steatosis.  The patient was treated with balanced crystalloids, pain medication, and was monitored for withdrawal.  It was reported that the patient had mild fingertip tremors with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score was 1-2.  The patient did not require or receive detoxification medication.  It was reported that the patient denied suicidal ideation, depression, or hopelessness as his depression and suicide risk screen were negative.  The patient was medically stable and 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 comorbid medical conditions including epigastric pain, but there were no reports of current or active alcohol withdrawal requiring detoxification medication.  The patient's CIWA score was 1-2 and he did not receive Lorazepam for detoxification.  The patient reported that he did not drink alcohol in one week prior to admission, and he had no reports of past withdrawal seizures or delirium tremens.  The patient had reports of medical issues but no reports of significant withdrawal symptoms from alcohol or substance use requiring detoxification treatment.  The risk of delirium tremens can occur 3-4 days after cessation of alcohol use.  However, this patient reported that he did not have a drink in one week, so it had past the high risk period for delirium tremens (DT's).  Also, the patient had no reports of acute psychiatric symptoms, such as suicidal or homicidal ideation, intent or plan, hallucinations, delusional or disorganized thinking, aggressive or self-injurious behavior, that would have required inpatient hospital treatment.  The patient had medical issues and his primary diagnosis was epigastric pain.  There were no reports of specific identifiable or quantifiable treatment objectives or goals that could only be achieved in a 24-hour inpatient hospital detoxification.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient hospital stays should be upheld.  The medical necessity is not substantiated.