Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Pneumonia, Substance Abuse.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was overturned in part. 

This is a male patient with history of diabetes mellitus (DM), hypertension (HTN), and ethyl alcohol (ETOH) abuse, who presented to the hospital with complaints of a syncopal episode while shopping.  The patient's Vital Signs at presentation to the Emergency Department (ED) were temperature (T) 98.9 F, heart rate (HR) 119, respiratory rate (RR) 18, blood pressure (BP) 121/66 mm Hg and oxygen (O2) saturations 96 %.  The patient denied any fever, shortness of breath (SOB) or chest pain.  The patient was noted to be Icteric and was tremulous and drowsy.  Laboratory work up revealed white blood cell (WBC) count 3.8K, hemoglobin (Hb) 12.5, and T Bili was 4.5.  AST, ALT and Alk Phos were also elevated.  BUN/ Creatinine were 48/4.5, and chest x-ray showed bilateral patchy infiltrates.  After a period of medical stability the patient was discharged.  A computed tomography (CT) of the head did not reveal any acute changes.  A computed tomography (CT) of the chest confirmed bilateral infiltrates.  Troponin was negative.  There were no acute EKG changes suggestive of ischemia or arrhythmia.  His medical management included intravenous (IV) hydration and IV antibiotics for treatment of bilateral pneumonia.  The patient was placed on an alcohol withdrawal regimen with Ativan, Thiamine and Vitamins.  Admission was appropriate due to presentation with renal failure, bilateral pneumonia, alcoholic hepatitis, ETOH withdrawal symptoms and syncope.  After a period of medical stability the patient was discharged.

Acute medical admission was appropriate as this patient had multiple medical problems acute renal failure, bilateral pneumonia, alcoholic hepatitis, alcohol withdrawal and syncope.  Due to multiple medical issues this patient was not stable to be treated in any other setting.  He needed strict input and output (I and O), close monitoring of electrolytes, liver function tests (LFT's), BUN/ Creatinine over several days.  He was also exhibiting signs of alcohol withdrawal and had alcoholic hepatitis, which needed close monitoring and this could not have been provided in any other setting.  The patient was evaluated by multiple consultants- Gastroenterology (GI), Renal, and Infectious Diseases (ID).

This patient was tolerating oral intake.  He had completed five days of antibiotics.  The patient was afebrile and hemodynamically stable with normal renal function.  There was no evidence of Hypoxia. The patient was stable to be switched to oral antibiotics at this time.  There was no sign of alcohol withdrawal at this time.  The patient was stable to be discharged home on oral medications with close monitoring in the outpatient setting.  The prior decision is modified.  Admission is partially approved.  Length of stay is denied for the last 4 days.  The health plan did not act reasonably with sound medical judgment with regard to the inpatient admission.

The carrier's denial of coverage for the inpatient level of care admission is modified.  Approved for the first 4 days, and denied the last 4 days.