Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse, transaminitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history significant for psoriasis, chronic alcoholism, and pancreatitis who presented to the emergency department with complaints of body shaking, sweating, and feeling anxious. The patient reported tremors and visual hallucinations. In the emergency department, she received Ativan and Valium because her Clinical Institute Withdrawal Assessment (CIWA) score was 16. 
At the time of the initial evaluation, the patient was afebrile. Her pulse rate was 81 beats per minute (bpm), respiratory rate 18, blood pressure 100/65, and oxygen saturation 98% on room air. 
The patient appeared to be in no distress. She had dry mucous membranes. She had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, and no guarding or rebound. The patient appeared lethargic. 
Laboratory evaluation revealed that the white blood cell count was 8.6, hemoglobin 11.5, hematocrit 34.6,and platelets 125. Sodium was 141, potassium 3.2, chloride 106, bicarbonate 25, BUN 8, creatinine 0.6, glucose 82. 

The patient was admitted to the hospital with alcohol withdrawal, transaminitis secondary to alcoholic liver disease, thrombocytopenia, chronic alcoholism, hypokalemia. 
On the next day after the day of admission, she was reevaluated by the attending physician who suggested that the patient's CIWA score was 1. The attending physician stated in the progress note that the patient received Diazepam and Librium on admission but did not require any additional doses of benzodiazepines since the admission. It was also noted that the patient received potassium supplements because of mild hypokalemia. 
On the next day, the attending physician stated that the patient had a CIWA score of 0 and still had not received any Ativan after the initial treatment with Diazepam and Librium provided at the time of admission. According to the same progress note, the patient was in stable clinical condition and was ready for discharge. 

At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 

Even though the patient demonstrated signs of alcohol withdrawal at the time of the initial evaluation, those symptoms were short-lived. After the initial period of stabilization, there was no evidence that the patient had severe alcohol withdrawal symptoms, including persistent tachycardia, nausea, vomiting, tremors, and increased perspiration. There was no history of delirium due to alcohol withdrawal, repetitive seizures, or unstable medical conditions that would significantly increase the risk of adverse outcomes related to withdrawal. According to the progress notes, the patient's CIWA score was in the range between zero and one, which correlates with essentially no withdrawal symptoms. There was no evidence that the patient posed a danger to herself or others. 

Overall, this patient remained in a relatively stable clinical condition after the initial care she received in the emergency department. 
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care, rather than admission to an inpatient level of care. 
Overall, she remained in stable clinical condition and did not need any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.