Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal and Pulmonary Embolism, chest pain. 
Treatment: Inpatient Admission.
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male with alcoholism who was admitted to the hospital with left-sided chest pain, shakiness, anxiety, and depression. The patient denied prior episodes, he denies hallucinations, and suicidal or homicidal ideation. There was no nausea, vomiting, abdominal pain, or diarrhea. His vital signs appeared stable on arrival. The last alcoholic beverage was 24 hours before this presentation. The examination showed an alert patient, with a normal cardiopulmonary examination. The laboratory studies showed a creatine kinase (CK) level of 224, his glucose was 119, his creatinine was 1, and his electrolytes were stable. His lipase was 68, his white blood cell count was normal at 10.5, and his hemoglobin was14.9. The patient's liver function tests (LFT's) were mildly elevated.

A computed tomography angiography (CTA) of the chest was completed because of the reported left-sided chest pain, which revealed a left lower lobe pulmonary artery filling defect suspicious for pulmonary embolism in the right clinical setting. The electrocardiogram (EKG) showed no segment (ST) elevations or strain. The patient was hospitalized for pulmonary embolism treatment and alcohol withdrawal. The medical team placed the patient on Lovenox and the Clinical Institute Withdrawal Assessment (CIWA) protocol. The plan was to transition the patient to direct oral anticoagulants (DOAC) the following morning, with an outpatient hematology and oncology workup.

The following morning the patient reported feeling much better. He reported the perianal and genital rash had been present for four months. The previous treatment included Acyclovir for herpes simplex virus (HSV) infection. The medical team requested testing for syphilis, gonorrhea, and a monkeypox swab and he was treated with intramuscular Penicillin, Cephalexin, Doxycycline, Hydrocortisone, and Clotrimazole. Additionally, they ordered an echocardiogram. The calculated pulmonary embolism severity index (Pesi) score was 41, which is a very low risk.
An infectious disease consultation was also obtained, who ordered rapid plasma reagin (RPR), and human immunodeficiency virus (HIV) testing. A pulmonology consultation was also requested, which reviewed the CTA and deemed that it was indeterminate for pulmonary embolism (PE), given a poorly timed contrast study and a repeat CTA was ordered.

The patient was found restless and anxious, with nicotine cravings. The echocardiogram was completed, and it was a normal study. The sexually transmitted disease panel was positive for syphilis, and he was treated with Ceftriaxone and Doxycycline. The Penicillin was not administered the previous day but was administered before discharge. The repeat CTA showed no evidence of PE. Therefore, anticoagulation was discontinued. 

A low-quality CTA of the chest in the emergency department (ED) was suggestive of a PE, which was found to be negative later on the repeat scan. Even if confirmed, the pulmonary embolism severity index (PESI) score was 41, indicating a very low risk for 30-day mortality, and the patient did not require admission for this condition.

There were secondary concerns about alcohol withdrawal, but the documentation fails to demonstrate persistently and severely elevated CIWA scores, hallucinations, hemodynamic compromise, or major electrolyte derangements to warrant an inpatient hospitalization. 

Evaluation, work-up, and treatment of sexually transmitted infections (STI's) are typically done in an outpatient setting and do not warrant an inpatient hospitalization. There was no evidence of a severe systemic illness, such as sepsis or septic shock related to a bloodstream infection, bacterial endocarditis, or severe dehydration.