Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol abuse and suicide attempt. 

Treatment: Continued inpatient hospital admission.

The insurer denied coverage for the continued inpatient hospital admission.

The denial is overturned. 

This is a male patient with a history of alcohol abuse, delirium tremens, and seizures, who was admitted to the Intensive Care Unit (ICU) after a suicide attempt, and he reportedly had alcohol withdrawal as he was drinking heavily. He reported that he was drinking alcohol every moment when not sleeping. He reportedly had past alcohol withdrawal seizures and delirium tremens. He reportedly was put on a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) protocol, had intravenous (IV) hydration, folic acid, and thiamine. He reportedly was transferred to the mental health unit when deemed medically clear. He reportedly had severe withdrawal again, including CIWA of 22 and had severe tremors and agitation. With his significant alcohol withdrawal history of delirium tremens and alcohol withdrawal seizures, he was put on a Librium CIWA protocol for detoxification. He reportedly stated that he wanted to kill himself, so he was transferred back to the mental health unit when medically cleared from detoxification.

This reviewer disagrees with the decision to deny coverage for continued inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient was a high risk patient medically and psychiatrically due to his continued severe withdrawal with a history of past alcohol withdrawal seizures and delirium tremens and continued suicidal plan after a suicide attempt which prompted an ICU admission.  

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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. This patient could not safely be treated in a less restrictive setting other than a 24 hour medical hospital treatment as he had severe withdrawal, including a CIWA of 22 and had withdrawal symptoms and a history of delirium tremens and alcohol withdrawal seizures which puts him at risk for life threatening withdrawal and delirium tremens again.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24 hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use large amounts of alcohol daily and reported drinking every minute that he was not sleeping and he had past reported complicated withdrawal including seizures and delirium tremens which require hospital treatment. He also needed detoxification medication to modify withdrawal and prevent even more severe and life threatening withdrawal again. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.  

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