Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Cardiac/Circulatory Problems
Primary Treatment: Inpatient Hospital

The patient is a male with a history of morbid obesity and alcohol abuse. In early 2019 a chest computed tomography (CT) angiogram showed a possible pulmonary embolism and he was prescribed Xarelto.  He presented to the emergency department complaining of chest pain, dyspnea and weakness.  He reported that he had been non-compliant with the Xarelto. His blood pressure was 131/90 millimeters of mercury (mmHg) with a heart rate of 65 beats/minute. He was oriented and initially had no tremor. His cardiovascular exam was unremarkable.  Chest CT angiography showed no evidence of pulmonary embolism. Review of the earlier scan suggested that what had been interpreted as a pulmonary embolus was likely artifact.  His serum troponin level was normal. He had no acute electrocardiographic changes.  While in the emergency department the patient developed tremor and tongue fasciculations. He was admitted for management of alcohol withdrawal. He was treated with lorazepam. The following day the physician progress note stated that the patient had a low Clinical Institute Withdrawal Assessment (CIWA) score and would likely be discharged the next day. 

The health plan's determination is upheld.

This patient was admitted for treatment of alcohol withdrawal. While alcohol withdrawal can lead to delirium tremens, which can be fatal, most patients with acute alcohol withdrawal do not need inpatient admission. The decision regarding inpatient admission should be based on the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA), which includes such factors as nausea, vomiting, tremor, diaphoresis, anxiety, agitation, itching, hallucinations, visual disturbances, headache and disorientation. According to current recommendations, patients with mild symptoms (CIWA score of less than 8 to 10) can be monitored on an outpatient basis and may not require medication. Patients with moderate symptoms (CIWA score of 8 to 15) may require medication to alleviate withdrawal symptoms and may be monitored on an outpatient basis, or admitted to the hospital, depending on the situation and their comorbidities. Patients with a CIWA score of 15 or higher or a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions should be admitted to the hospital.

The records provided do not document a CIWA score for this patient at the time of admission. However, the only element on the CIWA score that is mentioned is tremulousness that would indicate a score of 2 or 3. Thus, based on the records provided, the severity of this patient's alcohol withdrawal did not justify an inpatient admission. Moreover, there is no documentation of a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions that would have warranted inpatient care. While he did present with chest pain and shortness of breath, pulmonary embolism was ruled out, he had no acute electrocardiographic changes and his serum troponin level was normal. If it was deemed necessary to rule out acute coronary syndrome, this could have been accomplished under a lower level of care status. In this situation, this approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.