Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment: Inpatient admission 

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

This male reportedly was admitted to this inpatient hospital treatment after having a witnessed seizure with a tongue bite and it was reported that he was heavily drinking alcohol on the weekend. He reportedly had withdrawal symptoms including tremors and sweats during the week. When he arrived, he also had very high heart rate of 170. He reportedly had altered mental status with confusion. He reportedly had other medical issues including tachycardia of 170, low blood pressure of 96/58, hypokalemia with the need for K (potassium) supplementation, transaminitis, elevated LFT's (Liver function tests), elevated troponin and rule possible acute coronary artery disease or demand ischemia, mild rhabdomyolysis, and hepatic steatosis. 
  
The medical records provided enough specific evidence to support that he required this level of care then. Also, the US (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. Also, the MCG (Milliman Care Guidelines) Substance Related Disorder criteria report that one meets criteria if one was withdrawal signs with high risk indicators including one of the following: heart rate over 100, nausea/vomiting, tremors, increased perspiration, or other physical signs of alcohol or sedative withdrawal; elevated risk due to historical or combined factors with one of the following: history of delirium, seizures due to alcohol or sedative/hypnotics, intrinsic seizure disorder, pregnancy, or signs of medical disorders; severe alcohol or sedative withdrawal not manageable at a lower level of care with a heart rate over 120, severe vomiting, grossly visible tremor, temperature greater than 101 F (Fahrenheit) or 38.3 C (Celsius), or other physical signs; inadequate response to pharmacotherapy in the ED (emergency department) or an appropriate lower level of care or a lower level of care is not feasible or appropriate. This patient could not safely be treated in a less restrictive setting other than a 24-hour medical hospital treatment as it was reported that he had complicated withdrawal including withdrawal seizures and an elevated heart rate over 100 as it was documented at 170 in addition to altered mental status with concern for possible acute coronary artery disease or demand ischemia. In this case this patient had a witnessed withdrawal seizure with a tongue bite, and it was reported that his mother thought this was due to alcohol withdrawal as he was drinking heavily on the weekend including 1 liter of vodka. It also was reported that he had a seizure in the past after heavy alcohol use but left AMA (against medical advice) and without follow up. The medical records reported that his symptoms were consistent with alcohol withdrawal including the seizure and elevated heart rate.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.