Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a female with a history of polysubstance abuse on methadone, hypertension (HTN), lupus, asthma and alcoholic pancreatitis. The patient presented to the emergency room (ER) with epigastric abdominal pain and vomiting.  She also noted shortness of breath (SOB).  She did not drink alcohol on the day of presentation.  She vomited her methadone.  She had been seen in the ER for epigastric pain with negative work up.  

The patient's vital signs were as follows: temperature 98.2, pulse 103, respiratory rate 16, blood pressure (214/116), and oxygen saturation 99%.  The patient's Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was eight.  Her exam was remarkable for wheezes and epigastric tenderness.  Labs revealed the following: sodium (Na) 136, potassium (K) 3.7, blood urea nitrogen (BUN) / creatinine (Cr) 140/.6, white blood cell (WBC) 7.43, hemoglobin (H) / hematocrit (H) 15/44.1, platelets (Plt) 150, aspartate aminotransferase (AST) 195, alanine aminotransferase (ALT) 121, alkaline phosphatase (Alk Phos) 149, total bilirubin 0.8, and alcohol (EtOH) less than (<) ten.  The patient's chest x-ray (CXR) revealed nothing abnormal detected (NAD).  Electrocardiogram (EKG) revealed normal sinus rhythm (NSR).  Ultrasound (US) has nothing abnormal detected (NAD).  

The patient was treated with oral (PO) metoprolol in the emergency department (ED) with a repeat blood pressure of 192/108.  The patient was admitted with alcohol withdrawal.  Plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, nothing by mouth (NPO), intravenous fluids (IVF) at 75 cubic centimeters per hour (cc/hr), albuterol, famotidine, and resume home medications.  

The patient's blood pressure (BP) was up to 207/124 overnight with no symptoms.  Her current blood pressure (BP) was 154/94.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was less then (<) ten.  She had hand tremors and tongue fasciculations, and alcohol withdrawal with gastritis and hepatitis.  She was to continue Oxazepam.  She advanced diet and discontinue famotidine.  

The following day, the patient's blood pressure (BP) was up to 210/115.  Her current blood pressure (BP) was 181/100.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was three.  She had less hand tremors.  Her abdominal pain had resolved and she was tolerating diet.  Alcohol withdrawal was resolving.  Hydralazine was added to her antihypertensives.  

The next day, the patient's blood pressure (BP) was 162/97. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was zero.  She discontinued Oxazepam.  She as cleared for discharge to home.

No, the proposed treatment is not medically necessary.

This patient with a history of alcohol abuse and medication noncompliance was admitted after presenting with abdominal pain, vomiting and high blood pressure with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) wat an eight.  The patient was admitted with alcohol withdrawal.  The patient's hypertension responded to oral meds while in the emergency room (ER).  The patient had mild tachycardia and no arrhythmia.  There was no tachypnea.  Labs showed mild hepatitis but no end organ damage.   The patient was admitted with plan for intravenous (IVF) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  Home medications were resumed.  

On Day #2, the patient was able tolerate diet.  Blood pressure (BP) progressively improved with oral medications.  Clinical Institute Withdrawal Assessment (CIWA) progressively improved and on day #3, the patient was noted to have resolving alcohol withdrawal.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  She did not have symptoms that required an acute inpatient level of care.  The intervention provided did not require an acute impatient level of care.  She had not failed management at a lesser level of care.  

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner , 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.