Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for chronic disease, migraines, asthma, and anemia who presented to the emergency department after he was found nonresponsive next to pill bottles. Reportedly, the patient's wife stated that it was very likely that he also drank a significant amount of alcohol.
In the emergency department, the patient received treatment with normal saline. When the patient became more alert, he complained of dizziness, mild shortness of breath, and chest tightness.
When the patient was seen by the admitting physician, he was alert and awake and responded to all questions. At the time, the patient denied chest pain, palpitations, nausea, vomiting, diarrhea, abdominal pain, weakness, or any other symptoms. When seen by the admitting physician the patient was afebrile. Blood pressure was 133/91, heart rate 112 beats per minute (bpm), respiratory rate was 20 breaths/minute, oxygen saturation was within normal range.
The patient was alert, in no distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient was tachycardic, without murmurs, rubs, or gallops.
On the neuro exam, the patient was alert, oriented times four, and had no focal deficits.
The laboratory evaluation revealed that sodium was 139, potassium was 4.5, chloride was 101, bicarbonate was 22.1, blood urea nitrogen (BUN) was 7, creatinine was 0.63, and glucose was 196.
White blood cell count was 6.9, hemoglobin was 14.0, hematocrit was 33.0, platelets were 149. The urine drug screen was negative for everything. The ethanol level was elevated at 145.7.
Computed tomography (CT) scan of the head revealed no evidence of acute territorial infarct or hemorrhage.
The patient was admitted to the hospital with a diagnosis of altered mental status, unresponsiveness, drug overdose. Seizure precautions were implemented. Clinical Institute Withdrawal Assessment (CIWA) protocol was initiated.
In the hospital, the patient was seen by a psychiatrist who diagnosed the patient with alcohol abuse with intoxication and mood disorder. Based on the evaluation, it was suggested that the patient did not need continuous observation.
It was indicated that the patient had no evidence of tremor or withdrawal symptoms. Therefore, he was deemed stable for discharge.
The patient was advised to continue taking his routine medications for the management of Crohn's disease. He was also recommended to abstain from alcohol. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

The inpatient stay was not medically necessary. The patient presented to the hospital with altered mental status, which was most likely related to alcohol intoxication. However, there was no evidence that the patient had any signs of alcohol withdrawal including persistent tachycardia, nausea, and vomiting, tremors, or increased perspiration. There was no mention that the patient had a history of delirium or seizures due to alcohol withdrawal. There was no need for acute inpatient care related to acute toxicity since the patient was in relatively stable clinical condition, and in fact, became awake and alert while in the emergency department. The patient was evaluated by a psychiatrist who did not find a need for continuous monitoring. Therefore, neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care. The patient could have been managed at a lower level of care status.