Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Opiate and alcohol withdrawal
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of alcohol and heroin use. He presented to the ED (emergency department) complaining of a lump in his left forearm and requesting detox.

The patient had symptoms of anxiety, tremors, back pain and numbness of toes and fingers.  His vital signs were as follows:  Temperature 98.2, pulse 86, respiration rate 18, blood pressure 118/72. His COWS (clinical opiate withdrawal scale) score 8. His CIWA (clinical institute withdrawal assessment) score was 8. His exam was remarkable for moderate distress, thoracic and lumbar spine tenderness and diminished sensation in lower extremities, and left antecubital fossa lump that was erythematous and tender.

US (ultrasound) was consistent with left forearm cellulitis and small abscess. The patient's labs revealed the following:  WBC (white blood count) 7.34, H/H (hemoglobin/hematocrit) 15.5/47.6, Plt (platelets) 342, Na (sodium)139, K (potassium) 3.7, BUN/Cr (blood urea nitrogen/creatinine) 12/1, Lactate 2.4.  Urine tox screen was positive for methadone and opiates.  COVID test was negative. CXR (chest x-ray) revealed NAD (no active disease).

The patient was admitted with opiate and alcohol withdrawal and cellulitis.  Plan of care included IVF (intravenous fluids), IV (intravenous) antibiotics, Methadone, and Ativan.

The patient's vital signs were stable, and the patient was afebrile. The plan was to continue current management.

The patient's vital signs were stable, and the patient was afebrile. The patient requested to leave AMA (against medical advice).  He was changed to PO (oral) antibiotics.  He left AMA (against medical advice).

No, the Inpatient admission was not medically necessary.

Medically necessary services are those which are:
-safe 
-effective
-generally accepted national standard of medical practice 
-not provided primarily for convenience of the patient or the practitioner 
-the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient was admitted for alcohol and opiate withdrawal. The patient was hemodynamically stable and afebrile. He did not have tachycardia or have arrhythmia. He did not have nausea, vomiting, tremor, perspiration, delirium, seizures, or gross tremor. There were no physical signs of withdrawal. Labs were unremarkable. Comorbid condition included cellulitis of the arm. He did not have sepsis. The patient was admitted with plan for IV (intravenous) antibiotics and COWS/CIWA (clinical opiate withdrawal scale/clinical institute withdrawal assessment) protocol. He was noted to have mild withdrawal symptoms. Methadone and Ativan was started along with IV (intravenous) antibiotics. He remained clinically stable during hospital stay with no signs of severe withdrawal. The patient signed out AMA (against medical advice) on day #3. The patient was clinically stable and did not have findings of severe withdrawal or systemic infection. He did not have symptoms that required an acute inpatient level of care. He had not failed management in a lesser level of care. The requested inpatient admission was not medically necessary.