Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction/Alcohol Use, Unspecified, with Withdrawal
Inpatient Hospital Admission

Substance Abuse/Addiction/Alcohol Use, Unspecified, with Withdrawal.
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital stay as not medically necessary. The health plan's determination is overturned. 

The patient is a male who initially presented to the emergency department with concerns for left rib pain following a seizure. Pertinent history included epilepsy on Keppra, and alcohol use disorder complicated by withdrawal seizures. Additional history included a missed dose of Keppra the night prior. Initial vital signs revealed a temperature of 98.3F, a heart rate (HR) of 122 beats per minute (bpm), a blood pressure (BP) of 132/108 millimeters of mercury (mmHg), a respiratory rate (RR) of 15/minute, and a peripheral capillary oxygen saturation (SpO2) of 99%. Initial examination documented the patient as alert, oriented, without tongue fasciculations, and with very minimal bilateral hand tremor. An electrocardiogram (EKG) was unremarkable. A chest x-ray (CXR) was unremarkable. An extended release (XR) of the foot revealed nondisplaced fracture of 5th proximal phalanx. A computed tomography (CT) of the head and a CT-spine were unremarkable. Intravenous fluids, thiamine, folate, and benzodiazepines were provided. The patient was placed in the hospital thereafter with an impression of alcohol withdrawal seizures and alcohol use disorder. The admitting physician noted tremor, headache, nausea, and diaphoresis. Due to a Clinical Institute Withdrawal Assessment (CIWA) > 8, intravenous Diazepam was ordered. The patient had continued to receive benzodiazepines overnight. The patient requested to leave against medical advice and was cleared to do so.

The health plan's determination is overturned, in whole.

Yes. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was indicated as medically necessary for the entire admission.
Perry et al. note alcohol withdrawal is a common condition encountered in the hospital setting after abrupt discontinuation of alcohol in an alcohol-dependent individual. Patients may present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Management revolves around early identification of at-risk individuals and symptom assessment using a validated tool such as the revised Clinical Institute Withdrawal Assessment for Alcohol score. Benzodiazepines remain the mainstay of treatment and can be administered using a front-loading, fixed-dose, or symptom-triggered approach. Long-acting benzodiazepines such as chlordiazepoxide or diazepam are commonly used and may provide a smoother withdrawal than shorter-acting benzodiazepines. Patients with symptoms refractory to high doses of benzodiazepines may require addition of a rescue medication such as phenobarbital, propofol or dexmedetomidine.[1]
The patient presented with concerns of an alcohol withdrawal seizure. Pertinent history included prior alcohol withdrawal seizures. Initial evaluation documented the patient as alert, oriented, with tachycardia, with tremor, with elevated serum alcohol level, and with elevated lactate. Due to concerns for a withdrawal syndrome, intravenous benzodiazepines were administered. Thereafter, the patient continued to have a CIWA > 8 requiring additional doses of benzodiazepines. Following one night, the patient left against medical advice.
Moreover, clinical indications for admission to inpatient care were met. The patient had a history of repetitive seizures due to alcohol who presented following concerns of a withdrawal seizure. In addition, the patient had signs of withdrawal in the form of a heart rate greater than 120 beats per minute and a tremor. [2]