Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a female with a past medical history significant for asthma, seizures, depression, and multi-substance abuse who presented to the emergency department requesting detoxification from alcohol. According to the patient, she drank 1 Liter of vodka every day. The last drink was two days before the day of admission. The patient reported daily use of heroin, cocaine, marijuana, and tobacco. 

The review of systems was positive for swelling in the right foot for a few days following trauma. She also complained of chills but denied fever, cough, runny nose, shortness of breath, chest pain, or palpitations. At the time of the initial evaluation, the patient was afebrile, heart rate was 60 beats per minute (bpm), respiratory rate was 18 breaths/min, blood pressure was 120/76, and oxygen saturation was 100% on room air. 

The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable. 

Her laboratory evaluation revealed a white blood cell count at 4.8, hemoglobin was 13.1, hematocrit was 39.5, and platelets were 247. Sodium was 142, potassium was 4.6, chloride was 106, bicarbonate was 24, blood urea nitrogen (BUN) was 13.1, and creatinine was 0.73. Her urinalysis was unremarkable. A chest x-ray revealed right base consolidation that could be due to pneumonia or atelectasis. 

The patient was admitted to the hospital with the diagnosis of right lower lobe community-acquired pneumonia. The patient received treatment with ceftriaxone and azithromycin. The next clinical diagnosis was alcohol withdrawal, for which the patient was started on the Clinical Institute Withdrawal Assessment (CIWA) protocol. Other clinical problems at the time of admission included a history of withdrawal seizures, major depression, and polysubstance abuse. 

In the hospital, the patient was seen by a psychiatrist who stated that the patient had a history of depression. The psychiatrist also diagnosed the patient with alcohol use disorder and severe dependence, opioid use disorder, and cocaine use disorder. The psychiatrist recommended treatment with Mirtazapine every night. 

During the hospital stay, the patient remained in stable clinical condition. She was transitioned to outpatient care. At issue is the medical necessity of the hospital admission. 

The health plan's determination of medical necessity is upheld in whole. 
The inpatient hospital admission was not medically necessary for this patient. 
The patient had no clinical signs of pneumonia, she had no fever and had an unremarkable pulmonary exam. The patient had a history of polysubstance abuse and requested detoxification from alcohol. It was documented in the progress note that her CIWA score was 2 and was consistent with mild withdrawal symptoms. During the hospital stay, the patient remained afebrile and hemodynamically stable. She was evaluated by a psychiatrist who did not recommend inpatient psychiatric care. Overall, the patient remained in stable clinical condition and did not require diagnostic studies or procedures necessitating an inpatient hospital admission. 

Taking into consideration these facts, there is no evidence that either the severity of the patient's condition or the complexity of the services provided rose to an inpatient hospital admission. 

Therefore, the inpatient hospital admission was not medically necessary for this patient.