Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal and Lower Leg Infection.
Treatment: Inpatient admission.

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

The patient is a male. His history includes alcohol dependence and alcohol-induced cirrhosis. He presented to the emergency department for alcohol detox and one and a half months of bilateral lower extremity swelling with punctate opening with discharge.

The patient's Vital Signs were as follows: Temperature 98.3, Pulse 83, Respiratory Rate 19, Blood Pressure 127/85, Pulse oxygenation 98%. The patient's exam was remarkable for general swelling and lower leg edema. The patient's labs were as follows: White blood cells (WBC) 3.0, Hemoglobin/Hematocrit (H/H) 7.8/25.1, Platelet (Plt) 108, Sodium (Na) 37, Potassium (K) 4.2, Blood urea nitrogen/Creatinine (BUN/Cr) 4.5/.64.  The patient's Glucose was 91, BNP (brain natriuretic peptide) 441, COVID negative. The patient's urine toxicology was positive for methadone and ethanol. EKG (electrocardiogram) revealed normal sinus rhythm, QTc (corrected QT interval) 502. CIWA (clinical institute withdrawal assessment) score was 1.

The patient was admitted. Plan of care included IV (intravenous) antibiotics, anemia work up, and CIWA (clinical institute withdrawal assessment) protocol.

On day two, the patient's vital signs were stable. QTc (corrected QT interval) was 483. Chest x-ray showed blunting of right costophrenic angle. Lower extremity x-rays did not show osseous changes.  The plan was to discontinue IV (intravenous) antibiotics, because there was no evidence of cellulitis. He has years of lower extremity swelling. The plan was for venous studies. Vascular surgery was involved. It was noted that evaluation can be performed as outpatient.

On day three, the patient's vital signs were stable. Tremors were noted. The patient was dozing off during his exam. Lymphedema of legs was noted. Abdominal ultrasound showed fatty liver, splenomegaly, and gallstones and sludge. The patient's anemia was stable. Mild hepatic encephalopathy versus Ativan effect was noted. Lactulose and prednisolone were started. QTc (corrected QT interval) improved. The patient was transferred to floor. The plan was for outpatient colonoscopy.

On day six, the patient's vital signs were stable. Doppler ultrasound was ordered. The plan was for outpatient GI (gastroenterology) workup.

On day seven, the patient's vital signs were stable. CIWA (clinical institute withdrawal assessment) was 0. Doppler ultrasound was negative for DVT (deep venous thrombosis).

No, the Inpatient admission was not medically necessary.

The patient could have been safely and effectively treated at a lesser level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

This patient with a history of alcohol dependence and cirrhosis was admitted after presenting for detox and bilateral lower extremity edema. The patient was hemodynamically stable and afebrile. He had normal oxygenation. He did not have signs of alcohol withdrawal. Labs were remarkable for prolonged QT interval and anemia. He did not have severe electrolyte abnormalities. He did not have bacteremia. On day 2, antibiotics were discontinued after determining symptoms were secondary to lymphedema and QTc (corrected QT interval) was normalizing. He remained clinically stable during hospital stay. He did not have signs of severe alcohol withdrawal. It was recommended for additional GI (gastroenterology) and vascular surgery work up as an outpatient. This patient had not failed an outpatient or observation level of care. The Inpatient Hospital Admission was not medically necessary.