Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission .
The denial is overturned.

This male reportedly was admitted to an inpatient medical hospital due to alcohol withdrawal symptoms, dizziness, weakness, and dehydration. He reportedly had alcohol withdrawal symptoms including an elevated heart rate of 143 and tremors and he had a past reported alcohol withdrawal seizure. He reportedly had low potassium of 3.3, low magnesium and low platelets of 45. He reportedly had hypertension and diabetes. He reportedly was treated with 2 detoxification medications including Librium and Ativan and also treated with IV (intravenous) fluids. He reportedly was given Gabapentin. His Naltrexone was discontinued due to transaminitis.

The medical records provided enough specific evidence to support that he required this level of care then. 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 reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. He reportedly had a past withdrawal seizure and hospital treatment for detoxification is required for patients with current or past alcohol withdrawal seizures. He also reportedly had active alcohol withdrawal symptoms including tremors and a very high heart rate of 143 while drinking a large amount of alcohol as it was reported that he was drinking 1 pint of vodka 2-3 times per week. He also was considered at risk for more complicated and life-threatening withdrawal as the risk of delirium tremens can occur 3-4 days after alcohol use and he last used alcohol 2 days prior to admission. He also had comorbid medical conditions including having low potassium of 3.3, low magnesium and low platelets of 45 and had hypertension and diabetes. He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then.

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 the inpatient is overturned. Medical Necessity is substantiated.