Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol intoxication.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male. He has a history of multiple admissions for alcohol intoxication and cirrhosis.  The patient presented to the ED (emergency department) with alcohol intoxication.  He also reported worsening leg swelling due to medication noncompliance.

In the ED (emergency department), the patient's VS (vital signs) were as follows:  Temperature 98, pulse 105, respiration rate 15, blood pressure 127/72.  2L (two liters) NC (nasal cannula) were started after oxygen desaturation to 88 - 91% on RA (room air).  The patient's exam was remarkable for groggy appearing, bilateral injected conjunctiva, left eyelid ecchymosis, ascites, 2+ pitting LE (left extremity) edema, edematous fingers.  The patient's labs were as follows:  EtOH (alcohol) 491, ABG (arterial blood gas) 7.46/40/74/28/96, WBC (white blood count) 2.63, H/H (hemoglobin/hematocrit) 9.7/28.9, Plt (platelets) 45, Na (sodium) 148, K (potassium) 3.6, BUN/Cr (blood urea nitrogen/creatinine) 6/.55, PT (prothrombin time) 16.6, INR (international normalized ratio) 1.39, PTT (partial thromboplastin time) 37.1, AST (aspartate aminotransferase) 130, ALT (alanine aminotransferase) 30, Total Bilirubin 2.7, Direct Bilirubin 2.7.  CXR (chest x-ray) revealed left pleural effusion.  Chest CTA (Computed Tomographic Angiography) revealed no PE (pulmonary embolism).  Head CT (computed tomography) revealed NAD (no active disease).

The patient was admitted.  Plan of care included CIWA (clinical institute withdrawal assessment) protocol and GI (gastroenterology) consult.  GI (gastroenterology) notes ascites from decompensated liver disease.  The recommendation was for PO (by mouth) diuresis after paracentesis, EGD (esophagogastroduodenoscopy) as outpatient.

The following day, the patient's vital signs were stable.  O2 (oxygen) saturation was 97%.  The patient was feeling shaky and tremulous.  He was mildly anxious.  Librium taper was initiated.  The plan was for CIWA (clinical institute withdrawal assessment) every four hours, CATCH (Consult for Addiction Treatment and Care in Hospitals) consult, and continue PO (oral) diuretics.

The patient signed out AMA (against medical advice).

No, the Inpatient admission was not medically necessary.

Medically necessary services are those which are the following:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient was admitted after presenting with alcohol intoxication. The patient was hemodynamically stable and afebrile. He was found to have fluid overload secondary to decompensated liver failure and medical noncompliance. He did not have vomiting, delirium, seizures, or gross tremor. His exam was remarkable for ascites and LE (lower extremity) edema. Labs were remarkable for pancytopenia and alcoholic hepatitis. The patient was admitted with plan for diuresis and CIWA (clinical institute withdrawal assessment) protocol. He is noted to have symptoms of mild alcohol withdrawal. He signed out AMA (against medical advice). The patient was clinically stable and did not have findings of severe alcohol withdrawal or severe fluid overload that could not be managed at a lesser level of care. He had not failed management at a lesser level of care. The acute inpatient admission was not medically necessary.