Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction/Other/Alcohol withdrawal
Inpatient Hospital/inpatient emergency admission
The health plan denied the requested inpatient emergency admission as not medically necessary. The health plan's determination is overturned.

The male patient with a history of alcohol dependency and multiple admissions for acute alcohol withdrawal presented with a complaint of hematemesis associated with vomiting. Previous work-ups revealed severe exudative reflux esophagitis, mild erosive antral gastritis, and mild bulbar duodenitis during a previous admission, where no active bleeding was observed. However, the patient was readmitted after a fall due to alcohol intoxication and withdrawal, with a positive urine drug screen for cocaine, barbiturates, amphetamines, and cannabinoids. After stabilization and discharge, the patient resumed heavy alcohol consumption of up to 1 Liter of vodka daily. He came to the Emergency Care Center with blood-tinged emesis. The patient denied melena but reported the possibility of a maroon-colored stool. No other concerning symptoms were reported, such as syncope, lightheadedness, chest pain, dyspnea on exertion, or seizure activity. Vital signs indicated hypertension, while a physical examination revealed no acute findings. Further tests showed nonspecific ST-T wave changes on electrocardiogram, but no acute infarct or ischemia. A chest x-ray did not reveal cardiopulmonary abnormalities.

On the physical exam, the patient was afebrile. Respiratory rate was 18 breaths/min, with a blood pressure of 135/90 millimeters of mercury (mmHg), and an oxygen saturation of 100% on room air.

The patient received intramuscular (IM) Thiamine, intravenous (IV) fluids with multivitamins and folic acid, and additional tests were ordered, including a urine drug screen and culture. Admission was recommended based on the clinical findings. The admission diagnosis included alcohol withdrawal, vomiting, altered ketoacidosis, hypernatremia, severe hypomagnesemia, essential hypertension, and paroxysmal atrial fibrillation.
Clinical Institute Withdrawal Assessment (CIWA) protocol and treatment with Phenobarbital were initiated.
During the hospital stay the patient remained in stable clinical condition and tolerated oral intake. In the hospital, the patient was compliant with his regimen of medications. He received supplements due to electrolyte deficiencies. Since his clinical condition continued to improve he was transitioned to outpatient care.
At issue is the medical necessity for the requested health service/treatment of the inpatient emergency admission.

I overturn, in whole, the health plan's determination of medical necessity.

The admission at the acute inpatient level of care was completely justified based on the information provided. 
Admission at this level is typically required for patients with alcohol withdrawal who exhibit severe symptoms, such as a high CIWA score, persistent tachycardia, nausea, vomiting, tremor, increased perspiration, or have an elevated risk of adverse outcomes due to previous history or comorbidities. In this case, the patient presented with a high CIWA score of 28 indicating severe alcohol withdrawal symptoms. Additionally, the patient had electrolyte abnormalities, including hypokalemia and hypermagnesemia, as well as acid-base derangements reflected by an increased anion gap. Despite treatment, the patient's CIWA score remained elevated on multiple occasions, indicating the persistence of withdrawal symptoms.