Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal. 
Treatment: Inpatient Admission. 

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

This female with a history of alcohol abuse presented to the emergency department (ED) with alcohol intoxication.  Vital signs (VS) revealed temperature 98.6, heart rate 80, respiratory rate 20, blood pressure 112/78, and oxygen saturation 97%.  The patient's exam was unremarkable.  Labs were remarkable for alcohol (EtOH) 363.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 7.  The patient refused detox in the emergency department (ED).  She was given a total of 75 milligrams (mg) of Librium in the emergency department (ED).  While in the emergency department (ED). The patient became tremulous and had tongue fasciculation.  Repeat exam remarkable for abdominal distention, nontender.  The patient was admitted with alcohol withdrawal syndrome.  

The plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and intravenous (IV) antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis.  Admission day 2, vital signs were stable (VSS).  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 4.  Platelets were 26 as a result of alcohol-induced thrombocytopenia.  Admission day 3, vital signs were stable (VSS). Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 12.  Admission day 4, vital signs were stable (VSS). Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 13.  Ativan was increased to two milligrams very six hours (q6h) by mouth (po) and intravenous (IV) three times a day (TID) as needed (PRN).  Librium was discounted.  Admission day 5, vital signs were stable (VSS).  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 3.  Plan was to taper Ativan.  Admission day 6, vital signs were stable (VSS).  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 3.  The plan was for the last dose of intravenous (IV) antibiotics.  Admission day 7, vital signs were stable (VSS).  The patient was cleared for discharge. 

No, the proposed inpatient admission was not medically necessary. 

This patient was admitted after presenting with alcohol intoxication.  The patient was hemodynamically stable and afebrile.  She did not have tachycardia or arrhythmia.  She developed tremors while in the emergency department (ED), but did not have vomiting, delirium, or seizures.  The patient was admitted with plan for intravenous fluids (IVF) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  Empiric antibiotics were administered for spontaneous bacterial peritonitis (SBP) prophylaxis, but there is no documentation to support infection.  The patient remained hemodynamically stable during the hospital stay.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) increased, but exams did not reveal findings of severe alcohol withdrawal.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  She was able to be managed with oral (PO) Ativan.  She did not have symptoms that required an acute inpatient level of care.  She had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely.