Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is modified.

This patient was admitted to this inpatient hospital after being found obtunded and laying on the ground. He reported that he had a seizure and fell in the street. He reportedly had altered mental status and was minimally responsive to verbal stimuli. He reportedly was hypoxic with an oxygen saturation of 89% (percent). He reportedly had multiple medical issues including seizures, asthma, cirrhosis, hepatitis C, thrombocytopenia, leukopenia, prolonged PR (interval on electrocardiogram [EKG]) interval, and lower leg edema. He reportedly was found with altered mental status covered in emesis. He was started on a Clinical Institute of Withdrawal Alcohol Assessment (CIWA) protocol and given IM (intramuscular)Ativan for detoxification. He reportedly had multiple past inpatient alcohol detoxification treatments in which he left against medical advise (AMA). He reportedly was homeless. The recommendation was to be discharged to an inpatient alcohol rehabilitation treatment but he declined the recommendation and was discharged back to the shelter.

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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

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 this patient had comorbid medical conditions complicating the management of withdrawal and had active withdrawal requiring inpatient admission. Notes on admission reported that he was found obtunded and laying on the ground covered in emesis, reported that he had a seizure and fell in the street, and he had altered mental status and was minimally responsive to verbal stimuli. He also reportedly was hypoxic with an oxygen saturation of 89%. He reportedly had multiple medical issues including seizures, asthma, cirrhosis, hepatitis C, thrombocytopenia, leukopenia, prolonged PR interval, and lower leg edema. It was reported that he was given IM Ativan for detoxification. Notes reported that he received 2 mg (milligrams) of IM Ativan also for detoxification and still had elevated diastolic blood pressure and tremors. Notes reported that he had a CIWA of 6 and still had alcohol withdrawal symptoms and was taking Ativan 2 milligrams (mg) q[every] 8 hours for detoxification. Notes reported that he had a CIWA 3-6 and still had alcohol withdrawal and took Ativan 1 mg q 12 hours for detoxification. Notes reported that he had a CIWA of 0-6. He reportedly had a history of seizures and had active withdrawal of alcohol and was being treated with a CIWA protocol of Ativan.
  
The health plan acted reasonably in part with sound medical judgment with respect to level of care.

The insurer's denial of coverage for the inpatient admission is modified. Denial is partially substantiated.