Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient with a past medical history significant for alcohol abuse who presented to the emergency department with complaints of shaking and generalized body aches. The patient stated that he had been feeling nauseous and had vomited. There were no complaints of hematemesis, shortness of breath, fever. The patient denied any sick contacts or recent travel. In the emergency department, the patient was diagnosed with alcohol withdrawal symptoms. 

At the time of the initial evaluation, the patient was afebrile, blood pressure was 128/85, heart rate 120 beats per minute (bpm), respiratory rate 22, and oxygen saturation 100% on room air. The patient was awake, alert, and oriented. He was tremulous and appeared ill. His skin was slightly jaundiced. Lungs were clear to auscultation bilaterally. The gastrointestinal system examination was unremarkable. On the neurological exam, the patient was awake, alert, oriented times three, and cranial nerves were within normal limits. There were no focal deficits noted. The patient appeared anxious with no suicidal ideations. 

Transaminases were within normal limits. The lipase was normal. The patient was admitted to the hospital with a diagnosis of alcohol abuse and withdrawal symptoms as well as hypomagnesemia. The patient was placed on the Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient received treatment with Librium. Magnesium supplements were initiated. 

The patient was seen by an internal medicine physician again. At that time, the patient felt well. The review of systems was reviewed and was negative. The physical exam on that day, including the neurological exam, was unremarkable. The patient was continued on the CIWA protocol. 

Since his condition remained stable, the patient was discharged the next day. 
The health plan's determination is overturned in part. The inpatient stay was medically necessary for 1 day at the acute inpatient level of care because of the severity of the patient's condition defined by the CIWA score of 17 and the presence of electrolyte abnormalities. Principal indications for medically supervised alcohol withdrawal in an ambulatory setting are: 1) A patient with mild symptoms of alcohol withdrawal (CIWA-less than 15), or asymptomatic patients with a history of symptoms with past attempts to reduce their drinking. (See 'Assessment' above.), 2) No history of delirium tremens or alcohol withdrawal seizures. Additional indications for the ambulatory setting include: 
1) Cognitively intact and motivated to avoid alcohol. 2) Ability to take oral medications. 
3) Ability to commit to near-daily medical visits. 4) Absence of comorbid medical or psychiatric conditions and/or marked abnormalities on physical examination or laboratory evaluation. 

Patients with any of the following characteristics should undergo medically supervised withdrawal in an inpatient setting, allowing for more careful monitoring and more aggressive treatment (see "Management of moderate and severe alcohol withdrawal syndromes"): 1) Fever 2) Disorientation 3) Drenching sweats 4) Severe tachycardia 5) Hypertension 6) Pregnancy 7) Concurrent substance use that could lead to withdrawal symptoms (eg, benzodiazepines) 8) Markedly abnormal laboratory values

In this particular case, the patient had a CIWA score of 17, which was consistent with a moderate severity of withdrawal symptoms. In addition, the patient had electrolyte abnormalities in the form of hypomagnesemia. Taking into consideration this information, the admission at the acute inpatient level of care was justified on the first date of the admission. 

However, the patient's condition significantly improved overnight and his CIWA score decreased substantially on the next day after admission. The patient was given magnesium supplements with improvement in his serum magnesium level.
The additional stay did not qualify for the inpatient level of care. Although the patient was still watched closely for alcohol withdrawal symptoms, care could have been provided at a lower level than inpatient.