Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol dependence, abnormal EKG
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with alcohol intoxication. She was brought to the emergency department (ED) by Emergency Medical Services (EMS) after her boyfriend called. According to EMS, her boyfriend found her barely responsive. The patient was drinking heavily, The patient requested detoxification. The patient has a history of liver disease (liver ultrasound (US)- enlarged steatotic liver). She also had a history of paroxysmal atrial fibrillation. One week prior to this presentation, the patient felt a single episode of sharp stabbing pain on the left side radiating to her arm, and it spontaneously resolved, at rest her previous echocardiogram was done and it revealed normal left ventricular (LV) function.
In the ED, the patient was tachycardic with heart rate 102 beats per minute (BPM). Her ethyl alcohol (ETOH) level was 358. Her urine was positive for cannabis and Ethanol. Her lactate was 2.3 and ammonia was 85. Magnesium was 1.6. Troponin was normal. Transaminases were elevated. Her electrocardiogram (ECG) revealed intermittent junctional rhythm with the rate of 79 BPM with intraventricular conduction delay and left ventricular hypertrophy.
In the ED, the patient was given intravenous (IV) thiamine, magnesium and intravenous fluids (IVF). The patient was admitted to the hospital for observation for possible alcohol withdrawal. The patient was on continues IV hydration, "banana bag" and she was started on a Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient was transferred from telemetry in 24 hours and continued to be treated with CIWA protocol. Her albumin was low. The patient was ordered Lorazepam IV every 8 hours for two days, according to CIWA protocol. Her lab results were monitored every day. Her magnesium was replaced.
The patient's condition remained stable and she did not have any symptoms. Her CIWA was zero. She was overall asymptomatic.
Upon discharge, the patient refused an inpatient detoxification programs and indicated that she was going to be treated as an outpatient. At issue is the medical necessity of an inpatient level of care.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient presented being heavily inebriated. Her vital signs were stable. She had evidence of junctional rhythm on the ECG, but she was asymptomatic and her rate was normal.
The patient had some abnormal lab results due to alcohol abuse, and she received replacement. She was under CIWA protocol, however, she did not have evidence of clinical withdrawal, such as seizures, delirium tremens, or others. The patient's condition and her management did not meet criteria for inpatient admission; care could have been provided at a lower level.
Per reference 2, alcohol consumption is one of the most important risk factors for the global burden of disease and disability . Besides the health states directly related to alcohol consumption such as alcohol dependence or alcoholic liver cirrhosis, alcohol use is also causally linked to a wide range of acute and chronic conditions traditionally considered to be outside the addiction field. Several cardiovascular disease categories have been linked to alcohol, especially to heavy consumption, but the relationship to cardiac arrhythmias has not been included in most studies on alcohol-attributable mortality or burden of disease. Within the category of arrhythmias, atrial fibrillation (AF) has been discussed to be potentially caused by alcohol for several decades. AF is the most common arrhythmia in clinical practice with approximately 2.2 million people in America having paroxysmal or persistent AF. During the past 20 years there has been a 66% increase in hospital admission due to AF. In 1978, Ettinger linked heavy alcohol consumption on week-ends or holidays with the higher risk of the subsequent onset of cardiac disturbances, mainly AF, currently known as the "Holiday Heart Syndrome". Different studies have subsequently assessed the association between alcohol consumption and AF. All but one of these studies were conducted after the publication of the two meta-analyses on this topic, both of which dealt with the larger category of cardiac rhythm disorders based on the same two studies with the same pooled results, showing no significant differences for any drinking category. Several publications since the last meta-analysis highlighted the association between heavy alcohol consumption and increased risk of cardiac arrhythmias. For instance, significant risk was associated with 6+ drinks per day on average (greater than or equal to (= >) 48 grams (g)/day of pure ethanol) in a United Kingdom (UK) study; 5 plus (+) drinks = >60 g) per day for men in the Copenhagen City Heart study or 3+ drinks (= >36 g) per day in the Framingham study . On the other hand, the effects of light to moderate alcohol consumption on the onset of AF in the same studies could not be clearly established. The cited and other recently published studies enable not only a better quantification of the risks of the onset of AF related to alcohol consumption, but also the testing of the hypothesis of whether there is a threshold for the effect of alcohol exposure.