Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This patient reportedly was admitted to this inpatient hospital for alcohol detoxification treatment as they reportedly had withdrawal symptoms including tremors, diaphoresis, vomiting, elevated heart rate of 106, elevated blood pressure of 135/100, abdominal pain 9 out of 10, abdominal tenderness, and hypoxia. The patient reportedly had a Clinical Institute Withdrawal Assessment (CIWA) as high as 17 the next day. The patient reportedly had elevated liver function tests (LFTs) with an aspartate aminotransferase (AST) of 238, alanine aminotransferase (ALT) of 161, and lipase of 177. The patient reportedly was drinking 2 alcoholic beverages per day and 500 milliliters (ml) of whiskey per day. The patient reportedly had a medical history significant for untreated hepatitis due to prior heroin use. Also, there was suspicion of alcohol induced pancreatitis. The patient reportedly was in past outpatient alcohol rehabilitation treatment. The patient reportedly was treated with 2 detoxification medications including intravenous (IV) Phenobarbital 390 milligram (mg) and then oral Phenobarbital and also 7 mg of IV Ativan in addition to IV and oral analgesics. The patient reportedly was discharged after refusing the recommendation for continued inpatient alcohol detoxification treatment and then inpatient alcohol rehabilitation treatment.
 
The medical records provided enough specific evidence to support that the patient required inpatient hospital treatment for alcohol detoxification treatment then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence for 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, 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, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral), the patient did require 24-hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as they had active withdrawal symptoms including CIWA (Clinical Institute Withdrawal Assessment) of 17 and required 2 detoxification medications (Lorazepam and Phenobarbital) to modify withdrawal from alcohol and more severe withdrawal, complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens (DTs) can occur 3-4 days after alcohol use so the patient was considered at risk for DT's due to alcohol use daily with active withdrawal symptoms and a high CIWA trending in the wrong direction. 

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