Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse/Addiction
Treatment: Inpatient hospital admission
The health plan denied: Inpatient hospital admission
The determination is: Upheld

The patient is a male with a history of chronic alcohol drinking who presented to the emergency department (ED) experiencing shakiness after his last drink. He expressed his desire to find a place to stop drinking. The patient denied fever, chills, nausea, vomiting, or abdominal pain. Upon examination, the patient was found to be tachycardic, hypertensive, and tremulous. 
An initial laboratory evaluation revealed a lactate level of 3.9. Consequently, the patient was treated with intravenous (IV) fluids. The review of systems was negative for any symptoms except those mentioned above. 
During the physical examination, the patient was afebrile with a heart rate of 88 beats per minute (bpm), a respiratory rate of 18 breaths/minute, and a blood pressure of 148/83 millimeters of mercury (mmHg). The head, eyes, ears, nose, and throat (HEENT) examination showed no abnormalities. The patient exhibited tachycardia. Lung auscultation revealed clear breath sounds without wheezes, rales, or rhonchi. The abdomen was soft, and non-tender to palpation, with normal bowel sounds and no signs of guarding or rebound. Tremors were observed in the patient's hands. The rest of the physical examination was unremarkable. 
Laboratory evaluation indicated a white blood cell count of 10.6, a hemoglobin level of 14.2, a hematocrit of 42.2, and a platelet count of 325. The patient's electrolyte levels were as follows: sodium 142, potassium 4.1, chloride 103, and bicarbonate 26. Other laboratory results showed a blood urea nitrogen (BUN) level of 6, creatinine level of 0.92, and glucose level of 87. Liver function tests were unremarkable. 
Based on the clinical presentation and laboratory findings, the patient was admitted to the hospital with a diagnosis of alcoholism with signs of alcohol withdrawal. The Clinical Institute Withdrawal Assessment (CIWA) protocol was initiated for management. Additionally, the patient was diagnosed with lactic acidosis and received treatment with IV fluids. Hypomagnesemia was also identified, and the patient received magnesium supplements. However, the patient elected to leave the hospital against medical advice on the day following admission. 
At issue is the medical necessity of the inpatient hospital admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. 
The criteria for admission at the acute inpatient level of care for patients with alcohol withdrawal can vary based on the severity of withdrawal symptoms and the individual patient's condition. 
The review of the medical records clearly demonstrated that the patient had none of those criteria. His alcohol withdrawal symptoms were relatively mild. The patient was awake, alert, and oriented times 3 at the time of discharge. Furthermore, the discharging physician stated that the patient was completely asymptomatic, conversant, and capable of making his own decisions. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.