Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol detoxification and chest pain.
Treatment: Inpatient emergency admission.

The insurer is denied coverage for inpatient emergency admission.  The denial is overturned. 

This male patient has a history of hypertension, hyperlipidemia, gastritis, alcohol abuse disorder, and polysubstance use disorder.

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 detoxification treatment level of care, as he was at risk for severe, complicated, and life threatening withdrawal due to large amounts of alcohol use in addition to cocaine use as well as cannabis use and had multiple medical issues complicating the management of withdrawal and putting him at risk medically. He also was considered at risk for overdose due to large amounts of alcohol and cocaine use and he had reports of chest pain and elevated blood pressure in addition to active alcohol withdrawal symptoms. He reportedly had alcohol withdrawal symptoms including tremors, elevated blood pressure of 174/88, palpitations, hallucinations, anxiety, and had a Clinical Institute Withdrawal Assessment of 11, which increased to 16, so his withdrawal was worsening and put him at greater risk for more severe, complicated, and life-threatening withdrawal including delirium tremens.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of alcohol and cocaine despite current medical issues and he required and needed 2 detoxification medications, Librium and Ativan, to modify withdrawal including an Ativan taper. He needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically as well including chest pain, weakness, dizziness, gastritis, an electrocardiogram (EKG) revealing right bundle branch block and T wave inversions, sodium of 129 and chloride of 91, and an elevated blood pressure of 174/88, as well as an ultrasound revealing fatty infiltrate liver verses hepatocellular disease. He was considered a high risk patient medically and in need of 24-hour inpatient hospital treatment then. 

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

The carrier's denial of coverage for the inpatient emergency admission is overturned.  The medical necessity is substantiated.