Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.
Treatment: Inpatient hospital admission.

The insurer denied coverage for an inpatient hospital admission.  The denial is overturned.

This male reportedly was admitted to this inpatient hospital after a syncopal episode in which his sister found him on the floor. He reportedly had head trauma, urinary and bowel incontinence, and had headache, weakness, left eye bruising and swelling, tremors, tongue fasciculations, and an elevated heart rate as high as 122. He had abnormal labs including a sodium of 130, chloride of 90, CO2 (carbon dioxide) of 18, creatinine of .58, glucose of 259, and lactate of 515. There was concern for seizures due to alcohol withdrawal. He reportedly was drinking 4-5, 24-ounce beers daily, and it was reported that staff thought he was even minimizing his alcohol use. It was reported that his last drink was the day prior to admission. He reportedly had a CIWA (clinical institute withdrawal assessment) tool greater than 8 and was given intravenous (IV) Valium 10 mg (milligrams). He reportedly continued to report withdrawal symptoms and took IV Ativan 2 mg twice and po (oral) Valium 10 mg in addition to the above detoxification medication. It was reported that he also took Gabapentin for additional detoxification treatment. 

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients who exhibit 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. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at high risk for severe, complicated, and life-threatening withdrawal due to his large amount of alcohol use with current withdrawal symptoms and multiple medical issues. 

According to the LOCADTR (level of care determination) he did require 24-hour treatment, as he could not safely and effectively be treated in a less restrictive setting other than an inpatient medical detoxification setting, as he continued to use large amounts of and had active withdrawal symptoms with a CIWA above 8 with multiple medical issues. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical necessity is substantiated.