Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Alcohol Abuse/Addiction
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with anxiety, bipolar disorder, depression, alcohol abuse, alcohol withdrawal seizures, and a miscarriage in the past week, who presented to the emergency room (ER) with alcohol withdrawal. She reports drinking 6-12 beers daily for the past two weeks. Vitals on presentation included a temperature of 36.6C., a heart rate (HR) of 129 beats per minute (bpm), a respiratory rate (RR) of 18/minute, a blood pressure (BP) of 112/78 millimeters of mercury (mmHg), and an oxygen saturation of 100%. Labs were remarkable for a hemoglobin of 15.2 (high for young female), a bicarb of 18, an aspartate aminotransferase (AST) of 97, an alanine aminotransferase (ALT) of 38, and an alcohol level of 0.363. Per the ER note, the patient was in distress and was tremulous. In the ER, she received intravenous (IV) fluids, Phenobarbital, Ativan, Zofran, Pepcid, Reglan and vitamins. The patient was admitted  and was placed on Clinical Institute Withdrawal Assessment (CIWA) protocol along with seizure precautions on a telemetry unit. The CIWA score was high at 26, requiring Ativan. Inpatient events included tachycardia and hypoglycemia (glucose 74). The patient was continued on home Lamotrigine for seizures and was started on Librium for alcohol withdrawal. Fluids continued. The patient was discharged.
At issue is the medical necessity for the inpatient stay.

I overturn, in whole, the health plan's determination of medically necessity.

The inpatient level of care was appropriate for this patient during this admission. The patient needed to be admitted to the hospital and it was medically necessary, as she presented with signs of alcohol withdrawal (tachycardia, tremulousness) and reported a prior history of alcohol withdrawal seizures for which she was placed on an anti-seizure medication as an outpatient (Lamotrigine) per the chart. The patient meets Milliman Care Guidelines (MCG) criteria for inpatient admission for alcohol withdrawal with high-risk features (heart rate >100). Management of a patient with moderate to severe withdrawal is to utilize medications in the hospital, as recommended (Mirijello et al 2015). Further, the patient has a history of alcohol withdrawal seizures and required IV Phenobarbital in the emergency room, which has a narrow therapeutic window and requires close monitoring (Mirijello et al 2015). To monitor a patient with alcohol withdrawal requires a complex level of care and withdrawal is expected to last more than 2 midnights, thus qualifying the patient for inpatient status (CMS guidelines). The patient would have a high mortality risk if discharged due to the risk of delirium tremens with a mortality rate 20% with death commonly from infection, cardiac arrythmias, or respiratory collapse (Wolf et al 2020). The patient was tachycardic. The risk of delirium tremens is higher in patients who have previously had a complicated withdrawal, such as this patient with a history of prior seizures (Wood et al 2019). The patient has previously had alcohol withdrawal seizures, thus making her higher risk. In summary, the patient met criteria for the inpatient level of care.