Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse/Addiction
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The health plan's determination is: Overturned

The patient is a male with a history of Mallory-Weiss tear and chronic alcoholism, who was evaluated in the emergency department (ED) due to frequent falls. He has continued drinking at least one bottle of vodka daily for the past three years. He was experiencing falls and decided to seek help for alcohol abuse; therefore, he came to the ED. He has a prior history of alcohol withdrawals without any seizures. In review of the systems, he denied visual disturbances, headaches, or memory loss. The temperature was normal; the heart rate was 86 beats per minute (bpm), and the blood pressure was 161/94 millimeters of mercury (mmHg). He did appear to be shaking on the exam but was speaking in full sentences. He was diaphoretic. Laboratory studies revealed mild leukocytosis of 11.1, with stable electrolytes and renal function. Treatment in the ED consisted of phenobarbital and thiamine. Given his history of alcohol withdrawal, he was placed on the Clinical Institute Withdrawal Assessment (CIWA) protocol and provided with a Librium taper.

The following day, the vitals appeared stable, with a temperature of 97.6 Fahrenheit, a heart rate of 59 bpm, and a blood pressure of 150/81 mmHg. On exam, the patient was described as alert and oriented x3 (person, place and time), with the rest of the exam fairly unremarkable. Repeat labs showed mild hypokalemia of 3.4 but otherwise stable renal and hepatic function. An abdominal ultrasound was completed showing hepatic steatosis. The CIWA protocol was continued with Librium taper, folic acid, thiamine, and intravenous (IV) fluids. Hypokalemia was replenished. The disposition was determined to be home, with outpatient follow-up with Alcoholics Anonymous (AA). A head computed tomography (CT) scan was also obtained, given the frequency of falls, and was unremarkable.

The medical team documented no overnight events, stable vital signs, and an unchanged physical exam. Repeat labs were similar to the day before, with mild hypokalemia of 3.1. The CIWA scores were documented at 1-2, with no active signs of withdrawal. Similarly, the following day, the patient had no complaints, and no overnight events were reported. The potassium on this day was 3.5, with a magnesium of 1.8. The CIWA score was 0. The patient was deemed stable for discharge, with appropriate outpatient follow-up with AA.

At issue is the medical necessity of the inpatient admission. The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of inpatient admission is medically necessary for this patient.

Based on the provided documentation, the patient was at high risk for delirium tremens. He had a history of chronic alcohol abuse and consumed large amounts of hard liquor daily. He has a history of requiring intubation for alcohol withdrawal. On admission, he was diaphoretic and tremulous, tachycardic, with a CIWA score of about 11, placing him in at least a moderate risk category. Clinical guidelines dictate this to be an indication for inpatient admission. These factors made it reasonable to admit this patient under an inpatient level of care for close monitoring. Delirium tremens can occur within 72 hours of the last alcoholic intake. Therefore, given his history, it was reasonable to admit him under inpatient care, with monitoring extending to at least 72 hours.