Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

Based on the letter, the patient presented to the emergency department via ambulance, complaining of an acute onset of intermittent substernal chest pain earlier that morning. He has coronary artery disease, post percutaneous coronary intervention with three cardiac stents, heavy alcohol abuse with prior intensive care unit admission, hypertension, and hyperlipidemia. Review of the chart shows electrocardiograms (ECGs) with no acute ST-T (interval on an ECG) changes. An echocardiogram showed normal left ventricular function. Of note, while Troponin was ordered, no lab results were provided for review. He reported having wine that day. He reported drinking liquor daily.

A symptom-triggered approach is recommended for most patients to treat alcohol withdrawal when pharmacotherapy is indicated. It involves providing medication only when a patient has symptoms. To use this approach, a regular systematic assessment should be made of the patient's status using a validated instrument, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), a measure of withdrawal severity; < (less than) 10: Very mild withdrawal, 10 to 15: Mild withdrawal, 16 to 20: Modest withdrawal, > (greater than) 20: severe withdrawal. 

Suggested criteria for ICU (intensive care unit) admission of patients with alcohol withdrawal is:
Age >40, Cardiac disease (heart failure, arrhythmia, angina, myocardial ischemia, recent myocardial infarction), Hemodynamic instability, Marked acid-base disturbances, Severe electrolyte abnormalities (hypokalemia, hypophosphatemia, hypomagnesemia, hypocalcemia), Respiratory insufficiency (hypoxemia, hypercapnia, severe hypocapnia, pneumonia, asthma, COPD (chronic obstructive pulmonary disease)), Potentially serious infections (wounds, pneumonia, trauma, urinary tract infection), Signs of gastrointestinal pathology (pancreatitis, GI (gastrointestinal) bleeding, hepatic insufficiency, suspected peritonitis), Persistent hyperthermia (T (temperature) >39 C (Celsius)  [103 F (Fahrenheit)]), Evidence of rhabdomyolysis, Renal insufficiency or increased fluid requirements, History of prior alcohol withdrawal complications (delirium tremens, alcohol withdrawal seizures), Need for frequent or high doses of sedatives or an intravenous infusion to control symptoms, or Withdrawal despite an elevated ethanol concentration.
Asymptomatic or minimally symptomatic patients at lower risk for seizures or delirium tremens (DTs) who are being admitted to the hospital for other reasons should be closely monitored and may be treated with oral chlordiazepoxide 25 to 50 mg (milligrams)   (or oxazepam 10 mg) every hour as needed when a score of 8 or greater is achieved on the CIWA-Ar.
 
The CIWA (Clinical Institute Withdrawal Assessment) score was 5 (4 for tremor and 1 for headache). Which correlates to a very mild withdrawal. The patient was placed on a Librium taper. It appears that the patient decided to leave and at the time of discharge, the CIWA score was "4". 

The patient came to emergency room due to chest pain. The electrocardiogram showed normal sinus rhythm with an old inferior wall infarction. As noted above, while serial troponin levels were ordered, no results were provided. The CIWA score was "5" which correlates with very mild withdrawal and thus does not support need for admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.