Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Emesis
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned

This male reportedly was admitted to an inpatient medical hospital for emesis as he reportedly was vomiting for 2 days, had bloody vomit, and he had alcohol withdrawal symptoms including vomiting, tremors, tongue fasciculations, elevated heart rate of 110, elevated blood pressure of 172/144, abdominal pain, and constipation with a CIWA (clinical institute withdrawal assessment) of 22. He reportedly was drinking 5 glasses of rum with last use 2 days prior to admission. He had hypertension, gastritis, and migraine headaches. It was reported that gastritis verses gastric ulcer was suspected and rule out acute pancreatitis. He reportedly also had acute renal injury. Alcohol verses starvation ketosis secondary to intractable vomiting was reported. He reportedly was treated in the ED (emergency department) recently for similar symptoms. It was reported that he was given IV (intravenous) Ativan and Librium for detoxification treatment, thiamine, IV fluids, and was admitted to the medical unit for alcohol withdrawal detoxification treatment for possible impending DT's (delirium tremens) with a CIWA protocol including Ativan prn (as needed) and IV fluids. 
    
I disagree with the decision to deny coverage for inpatient medical hospital as the medical records provided enough specific evidence to support that he required this level of care then. The APA (American Psychological Association) 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. 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 alcohol and had active withdrawal symptoms with a CIWA as high as 22 with multiple medical issues despite past treatment episodes. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.

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.