Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld in whole.

The patient is a female who presented to the emergency department complaining of chest pain, palpitations and dyspnea. She reported an episode of vomiting earlier in the day. Her medical history was remarkable for hypertension, prediabetes and alcohol abuse. Her blood pressure was 155/94 millimeters of mercury (mmHg) with a heart rate of 122 beats/minute. Her respiratory rate was 20/minute with a room air oxygen saturation of 97%. On physical exam she was tremulous and appeared anxious. She had a history of alcohol abuse. She was hypomagnesemic and hypokalemic. Her liver function tests were abnormal and consistent with alcoholic hepatitis. Her electrocardiogram showed sinus tachycardia without acute ischemic changes. The QT interval was prolonged. Her serum troponin level was normal. Chest X-ray showed no acute pathology. Her Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA) score was 7. The patient was treated with intravenous fluids, thiamine, famotidine, lorazepam and electrolyte repletion and admitted to the hospital for treatment of alcohol withdrawal and possible alcoholic gastritis. Her CIWA score was 6. Her QT interval was improving with electrolyte repletion. The next day her CIWA score was 1. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld in whole.

An inpatient hospital admission was not medically necessary for this patient. This patient was hospitalized for possible 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. 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. This patient's initial score was 7 and decreased after admission. 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. Given her electrolyte abnormalities and prolonged QT interval, monitoring while her electrolytes were repleted was reasonable. However, this did not warrant an inpatient level of care. The patient could have been managed at a lower level of care status.