Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disease.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of chronic obstructive pulmonary disease (COPD), alcohol abuse with a history of an alcohol withdrawal seizure previously, hypertension, and hyperlipidemia. He presented to the emergency department after a physical fight and with a concern for wheezing, shortness of breath, a cough, and symptoms of alcohol withdrawal.
On presentation, the patient was afebrile with a blood pressure of 135/92, heart rate 113, respiratory rate 19, and an oxygen saturation of 96% on room air. The exam otherwise noted him to be alert and oriented with tremors and tongue fasciculations, and to have wheezing and rhonchi in addition to a hematoma over his left forearm, scabbed abrasions on his forehead, and multiple abrasions to his hands without focal hand or facial deformity noted. Labs resulted with a white blood cell count (WBC)of 16, hemoglobin (HGB) 13.3, platelets 158, sodium 143, potassium 3.2, blood urea nitrogen (BUN) 11, and creatinine 0.55. A computed tomography (CT) scan of the head showed no acute process. X-rays of the chest, forearms, and hands showed no evidence of fracture. The patient was given Librium, prednisone, Benadryl, ibuprofen, and nebulizers in the emergency department. He was subsequently brought into the hospital with concern for a COPD exacerbation, alcohol withdrawal, and left arm human bite wound with an abscess and with plans for prednisone, nebulizers, ceftriaxone, clindamycin, surgery consult for consideration of incision and drainage, continuation of Librium with Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal, and addiction medicine consultation.
The patient was seen by addiction medicine after presentation with a recommendation to continue Librium taper with 50 milligrams (mg) oral as needed every 4 hours for breakthrough withdrawal symptoms, and with the assessment that the patient would be a good candidate for inpatient rehabilitation after he was medically cleared.
The patient was hemodynamically stable without persistent tachycardia or severe hypertension. His CIWA scores were consistently less than (<) 10. There were no notes of ongoing significant withdrawal with persistent nausea/vomiting, altered mental status, seizures, or evidence of delirium tremens and he was able to be well-managed on the Librium taper without need for intravenous (IV) benzodiazepines.
Otherwise, with regards to his arm wound, he was seen by orthopedic surgery with the assessment that no surgical intervention was needed for his arm and with the recommendation to continue IV antibiotics. He was subsequently transitioned to oral antibiotics.
For his COPD exacerbation, he was continued on nebulizers as well as oral prednisone and was not noted to have hypoxia or tachypnea. He was deemed stable for discharge.
At issue is whether care at the inpatient level of care was medically necessary.

No, inpatient stay was not medically necessary. This patient presented with mild withdrawal as manifested by CIWA scores consistently < 10 and tremors in addition to a mild COPD exacerbation and arm wound. His alcohol withdrawal was able to be easily managed with a scheduled Librium taper without IV medications required, and his COPD exacerbation was managed with oral prednisone and duonebs without tachypnea noted. He otherwise received IV antibiotics initially for his arm but was quickly transitioned to oral antibiotics without incision and drainage needed and in the setting of the patient not having any high risk comorbidities placing him at risk of systemic complications from his abscess or prolonged recovery (he did not have a history of immunocompromise, diabetes mellitus, etc.). Given the presentation described and the low intensity of service described, it is unclear why he could not have been safely cared for at a lower level of care with oral prednisone, oral Librium taper, CIWA protocol, nebulizers, and IV antibiotics that were quickly switched to oral. Inpatient level of care was not medically necessary.