Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse 
Treatment: Inpatient hospital stay 

The patient has a past medical history significant for alcoholism who presented to the emergency department with alcohol intoxication and requested alcohol detox. The patient admitted to intermittent binge drinking for many years and admitted to drinking one bottle of vodka daily, and the last drink was on the day of admission. When the patient initially was evaluated in the emergency department, the patient had minimal withdrawal symptoms such as restlessness and tremors. On the physical exam, the patient was afebrile, heart rate was 119 beats per minute (bpm), respiratory rate 20, blood pressure 144/88, oxygen saturation 94% on room air. The patient appeared well-developed, the head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The cardiovascular exam was unremarkable. The pulmonary exam did not reveal significant abnormalities. The abdominal exam was benign. The patient had minimal tremors. 

When seen in the emergency department the patient was not oriented to time and place. At the time of the initial evaluation, the patient underwent a computed tomography (CT) scan of the brain without contrast that demonstrated no evidence of acute intracranial hemorrhage, mass effect, midline shift, or acute territorial infarct. According to the history and physical (H&P) , the patient was held in the emergency department for several hours. During this time the patient started to exhibit active withdrawal symptoms including sweats, chills, nausea, vomiting, restlessness, and tremulousness. The patient was admitted and started on Librium as needed for withdrawal symptoms, Vistaril for anxiety, multivitamins, and some other medications for symptomatic treatment of alcohol withdrawal. The alcohol withdrawal symptoms were very mild, and at the end of the hospitalization, the patient was discharged home. The health plan's determination of medical necessity is upheld in whole. According to the Merck Manual Professional Version, "A mild alcohol withdrawal syndrome includes tremor, weakness, headache, sweating, hyperreflexia, and gastrointestinal (GI) symptoms. Tachycardia may be present and blood pressure can be slightly elevated. Symptoms usually begin within about 6 h of cessation. Some patients have generalized tonic-clonic seizures (called alcoholic epilepsy, or rum fits) but usually not > 2 in short succession. Seizures generally occur 6-48 h after cessation of alcohol." CIWA-Ar scale is the Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-Ar) that has been the most studied and is the most widely used. The CIWA scale can help determine the need for medically supervised withdrawal management. In this clinical case, the CIWA alcohol scale was utilized. It was implemented on multiple occasions throughout the hospitalization and the score was recorded. In this clinical case, the patient had only one score recorded greater than 20 which was consistent with severe withdrawal. Admission at a lower level of care was appropriate for monitoring of alcohol withdrawal symptoms to ensure clinical stability and proper recovery. 

In addition, this patient was afebrile, hemodynamically stable, had clinically unremarkable laboratory results, and no concomitant conditions that would necessitate admission at the acute inpatient level of care.