Diagnosis: Acute Coronary Syndrome
Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was overturned.

This is a male patient who was admitted to inpatient hospital with complaints of chest pain that lasted an hour and very high blood pressure of 168/130 and then 194/130. It was reported that the patient had a history hypertension, erectile dysfunction, and substance abuse. The patient had withdrawal symptoms that included nausea, over 10 episodes of vomiting, diaphoresis, tremors, agitation, and anxiety; the patient's Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score was 13. The patient had a diagnosis of alcohol withdrawal and rule out unstable angina with acute coronary artery syndrome. The patient reported taking Suboxone and had a past hospitalization a few months prior to admission due to passing out. He was started on a Librium and Ativan protocol but signed out against medical advice (AMA).

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. In this case, this patient had active alcohol withdrawal symptoms with serious comorbid medical conditions including very high blood pressure with chest pain complicating the management of his alcohol withdrawal.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not have been safely and effectively treated in a less restrictive detoxification setting as he required and received detoxification medications to modify his withdrawal symptoms. The patient was treated with Librium and Ativan, and the patient needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms. The patient was at risk for worsened withdrawals and serious medical consequences as his blood pressure was very high and he had chest pain. The risk of life complicated withdrawal symptoms such as delirium tremens can occur 3-4 days after alcohol use so this patient required the entire time in this hospital even though he left against medical advice (AMA).

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 hospital admission should be reversed. The medical necessity is substantiated.