Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain, Alcohol Withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital with a chief complaint of lower abdominal pain, present for 3-4 days, becoming acutely worse on the day of admission. The pain was in the lower abdomen, the bilateral quadrants, intermittent, and cramping in quality. The pain was aggravated by eating and drinking, with associated nausea and a few episodes of vomiting. The patient also experienced some brown-colored diarrhea. Heavy alcohol use was reported for the past week. The patient has a history of alcoholism, leading to a ruptured duodenal ulcer 6 months before this presentation requiring intensive care unit (ICU) stay. He reported drinking 15 tallboy beers daily.
On exam, the temperature was 98.7 degrees Fahrenheit, blood pressure 171/80, heart rate of 93, and normal oxygen saturation. The abdominal exam showed an obese nondistended abdomen with normal bowel sounds. The patient was tender throughout, most notably in the right upper quadrant and bilateral lower quadrant, without rebound or guarding. The rest of the exam is documented as fairly normal.
Laboratory studies on arrival showed a hemoglobin of 11.1, low mean corpuscular volume (MCV) of 71, and platelets of 34,000. The international normalized ratio (INR) was 1.4. The electrolytes were normal, as was the renal function; the liver function tests (LFTs) showed an elevation of aspartate aminotransferase (AST) at 292 and alanine aminotransferase (ALT) at 101. The total bilirubin was 1.3. Lipase was elevated at 463; the initial lactic acid level was 3.5, subsequently decreased to 2.2. The alcohol level was elevated. The urinalysis showed no evidence of a urinary tract infection (UTI).
A computed tomography (CT) scan of the abdomen and pelvis with contrast showed a small to moderate amount of ascites. The gallbladder was distended, but no gallbladder wall thickening was noted. No definitive signs of cholecystitis were noted. The patient had hepatic steatosis on the computed tomography (CT) scan and signs of early cirrhosis. The pancreas appeared unremarkable on the scan.
The issue for review is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient.

This patient presented to the hospital with abdominal pain and was found to have an elevated lipase, lactic acidosis, alcohol intoxication, followed by alcohol withdrawal symptoms. The patient scored between 6 and 13 on a CIWA scale for several days per the nursing notes. The patient required treatment with intravenous (IV) lorazepam. Also, he was receiving IV morphine for abdominal pain. For alcohol withdrawal symptoms of this nature, inpatient hospitalization is warranted. Also, the patient had evidence of new thrombocytopenia, suggestive of decompensated liver disease, mildly elevated INR, suggestive of synthetic liver problem, imaging studies worrisome for gallbladder disease, and possible colitis based on the CT scan. When all of these factors are considered, the expected length of stay for this patient is greater than 48 hours. A lower level of care was inadequate for the complexity of this patient's presentation.