Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol withdrawal symptoms.
Treatment: Inpatient admission.

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

This adult male reportedly was admitted to this inpatient hospital treatment due to alcohol withdrawal symptoms and left sided rib pain after falling and fracturing his ribs. He reportedly had very high blood pressures of 195/120 and elevated heart rate as high as 130, tremors, tongue fasciculations, and he was disoriented and lethargic and in pain and had a CIWA (Clinical Institute Withdrawal Assessment) of 13, which then increased to 14. He reportedly was given Ativan 1 mg (milligram) IVP (intravenous push) for detoxification treatment. It was reported that he remained hypertensive with blood pressures of 180/113 and 166/11 with tremors. He was given Librium 25 mg for detoxification treatment and was admitted to telemetry with seizure precautions and IV (intravenous) fluids. He was given IV pain medication and antihypertensive medication. His CIWA eventually decreased to 1, his blood pressure was lowered, and his transaminase resolved so he was discharged.

The medical records provided enough specific evidence to support that he required this level of care. The APA (American Psychiatric 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 it reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 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. In this case the patient had several comorbid medical conditions complicating the management of withdrawal including very high blood pressure up to 195/120, and he had increasing CIWA scores from 13 to 14, and he required IV Ativan and Librium for detoxification. 

According to the Level Of Care Determination (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily
including up to 2/3 liter of vodka per day, and he fell and fractured his rib and had severe pain, which required treatment. He also required antihypertensive treatment and was considered more at risk medically due to high blood pressure and active withdrawal which was worsening. He required 2 detoxification medications. The risk of delirium tremens (DT) can occur 3-4 days after alcohol use, so he was considered at high risk for DT's due to his large amount of alcohol use daily with active withdrawal symptoms that were worsening. He was considered a high medical risk. 

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 full hospital admission is overturned.  Medical Necessity is substantiated.