Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Substance abuse/Addiction-Alcohol withdrawal
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

This is the case of a patient with past medical history of depression, hypertension, asthma, alcohol abuse in addition to heroin and cocaine abuse, who presented to the emergency department with nausea, anxiety, abdominal pain, reports of visual hallucinations, and headache in addition to suicidal ideation and desire to seek detoxification from alcohol. On presentation, the patient was afebrile with blood pressure 138/86, heart rate 88, respiratory rate 18, and oxygen saturation 96% on room air. Exam otherwise noted patient to be alert and oriented without tremor, focal neurologic deficits, or other acute exam abnormalities noted. Clinical Institute Withdrawal Assessment (CIWA) score was noted to be 15 initially and then 6 on reassessment. In the emergency department, the patient received Toradol intravenous (IV), Zofran IV, Pepcid IV, Mylanta, and Librium oral. The patient was subsequently brought into the hospital with concerns for suicidal ideation, depression, alcohol abuse, rhabdomyolysis, asthma, and elevated liver enzymes in the setting of alcohol abuse, and with plans for 1:1 sitter, psychiatry evaluation, CIWA protocol, IV fluids, thiamine, folate, follow up labs, and a computed tomography (CT) scan of the abdomen and pelvis.
Psychiatry saw the patient with assessment that he was cleared for outpatient follow up from a psychiatry standpoint. CT of the abdomen and pelvis resulted with no acute process. The patient was ultimately discharged to rehab.

Inpatient level of care was not medically necessary for this patient with persistently low CIWA scores, no noted history of alcohol withdrawal seizures, normal mental status, and hemodynamic stability throughout the hospital course. Lower level of care services rather than inpatient level of care were appropriate.
This is a patient who presented with alcohol intoxication and with initial concern for suicidal ideation requesting alcohol withdrawal. Though the CIWA was 15 on initial presentation to the emergency department, the patient was alert and oriented, with tremors, no active vomiting, or persistent hemodynamic instability, and his CIWA was noted to be 6 at the time he was seen by the admitting physician. He subsequently remained in the hospital  with CIWA scores recorded all less than 8, and the patient hemodynamically stable, alert, and oriented, and with no new acute issues arising. He otherwise on presentation was noted to have suicidal ideation with the patient cleared for outpatient psychiatry follow up, and very mild elevation of his creatinine kinase and liver enzymes, both of which improved quickly with IV fluids and within a reasonable period at a lower level of care. It is not clear why this patient could not have been safely treated in a lower level of care in the setting of mild alcohol withdrawal with CIWA scores all less than 8 after emergency room interventions, no altered mental status, persistent vomiting, or tremors, and with no other new acute medical issues arising after presentation. Inpatient level of care was not medically necessary.