Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse/Addiction
Secondary Diagnosis: Orthopedic/Musculoskeletal-Other-Rhabdomyolysis
Treatment: Inpatient Hospital
The health plan denied the inpatient stay. 
The health plan's determination is upheld in whole. 

The patient has a past medical history significant for alcoholism who presented to the emergency department asking for detoxification.
At the time of the initial evaluation in the emergency department, the patient exhibited signs of alcohol withdrawal that included severe anxiety, tremor and hot/cold sweats. The patient reported that he had alcohol withdrawal seizures in the past. The review of systems was negative for fever, chills, headache, suicidal or homicidal ideations, hallucinations, chest pain, shortness of breath, cough, or weakness in the extremities. The patient had an abrasion on the right cheek but no acute bleeding. The patient had tachycardia, but the rhythm was regular, without murmurs, rubs, or gallops. The patient had tremors in the bilateral upper and lower extremities. The rest of the exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 6.69, with a hemoglobin of 15.5, a hematocrit of 43.6, platelets of 133, a sodium of 130, a potassium of 3.5, a chloride of 89, a bicarbonate of 25, a blood urea nitrogen (BUN) of 10, a creatinine of 0.8, a glucose of 133, anaspartate aminotransferase (AST) of 308, an alanine aminotransferase (ALT) of 306, a total bilirubin of 1.7, a creatinine phosphokinase (CPK) of 2060 and an ethanol level of 145.
The patient was admitted to the hospital with a diagnosis of rhabdomyolysis and alcohol withdrawal. At the time of admission, the patient received treatment with intravenous fluids. Clinical Institute Withdrawal Assessment (CIWA) protocol was implemented.
During the hospital stay the patient remained hemodynamically stable. His mild rhabdomyolysis significantly improved. At the time of discharge, the patient had no alcohol withdrawal symptoms. The patient was able to ambulate with minimal assistance. Therefore,the patient was discharged from the hospital. 


The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The admission at a lower level of care was justified, to ensure that the alcohol withdrawal symptoms were resolving as well as to ensure resolution of rhabdomyolysis and stability of the kidney function and electrolytes.

The patient presented to the hospital with alcohol withdrawal symptoms, however, these symptoms subsided within a relatively short period of time and, on the day of discharge, the patient had no alcohol withdrawal symptoms reported. This includes the resolution of tachycardia. During the entire hospitalization, the patient remained hemodynamically stable. In the hospital, the patient had relatively low CIWA scores, consistent with mild alcohol withdrawal symptoms.
The rhabdomyolysis that was diagnosed at the time of admission was mild and responded to treatment with intravenous fluids very quickly. The rhabdomyolysis did not cause any significant complications such as acute kidney injury or electrolyte abnormalities. The rhabdomyolysis was diagnosed because of elevated CPK levels. Although these levels were abnormal, they were not high enough to cause significant complications.
Therefore, the patient could receive treatment with intravenous fluids and have CPK levels checked at a lower level of care.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.