Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse
Treatment: Inpatient Emergency Admission
The insurer denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a male with a history of alcohol abuse, delirium tremens, bipolar disorder, anxiety, depression, hypertension, high cholesterol, essential tremors, and sleep apnea who presented to the emergency department after his sister called 911. The patient reported consuming three pints of alcohol per day, with his last drink being two days before the presentation.
During the evaluation in the emergency department, the patient was noted to be slightly anxious and slightly tremulous. He reported that he had stopped drinking alcohol approximately 36 hours before his presentation and was not feeling well. He further stated that he had been experiencing visual hallucinations, specifically seeing scary faces while lying in bed. Upon further inquiry, he mentioned that these hallucinations occurred intermittently, lasting for about half an hour to an hour at a time. The patient exhibited marked flushing of the skin and sweating. He denied any history of psychosis but acknowledged that his depression and anxiety were well-managed with a daily intake of Wellbutrin 150 milligrams (mg) extended release (XL) and Seroquel 100 mg at bedtime. The patient expressed an interest in undergoing detoxification.
By the time the patient was seen by the admitting physician, his clinical condition significantly improved, and according to the admitting physician, the patient's Clinical Institute Withdrawal Assessment (CIWA) score was zero. Upon assessment, the patient's vital signs were stable, with a temperature of 37, a pulse rate of 84 beats per minute (bpm), and a respiratory rate of 19 breaths per minute.
Upon physical examination, the patient was observed to be well-developed and well-nourished. His head appeared atraumatic, with dry mucous membranes and clear nasal mucosa. No vesicles or oropharyngeal exudates were found, and the uvula was in the midline. The patient had no lymph node enlargement on the face. The examination of the eyes revealed clear bilateral vision, with equal, round, and reactive pupils. The cardiac evaluation showed a normal heart rate with a regular rhythm. He had no heart murmurs, rubs, or gallops. The respiratory assessment revealed clear and equal breath sounds bilaterally, with no wheezes, rhonchi, or rales.

The patient was admitted to a medical unit and started on CIWA protocol. On the next day after the day of admission, his symptoms improved and the CIWA score was calculated at 4. Since the patient's symptoms improved and he remained in stable clinical condition, he was deemed stable for discharge on the day after admission.
 
The inpatient emergency admission was not medically necessary. It was determined that the patient did not require treatment or inpatient emergency admission for alcohol withdrawal. The patient's reported symptoms, including visual hallucinations, marked flushing of the skin, and sweating initially raised concerns of a moderate to severe alcohol withdrawal syndrome. However, upon evaluation, the patient's CIWA score was zero, indicating a lack of significant withdrawal symptoms.
There were no reported seizures, signs of dehydration, or significant electrolyte imbalances, which are potential complications of alcohol withdrawal. The patient did not have any coexisting medical conditions that necessitated acute inpatient care, as indicated by the medical records. There was no evidence of a lack of social support at home, and the patient's hospital stay was brief, suggesting that the alcohol withdrawal symptoms were mild.
 
According to the MCG Health Inpatient & Surgical Care 26th Edition criteria for Substance-Related Disorders, there is no overwhelming evidence that the patient met those criteria in this clinical case.