Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction-Alcohol Abuse/Addiction- Withdrawal
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a case of a patient admitted to the Hospital for the diagnosis of alcohol withdrawal. The patient presented to detoxification for alcohol use disorder. In the emergency department he was noted to have a Clinical Institute Withdrawal Assessment (CIWA) greater than 16 and was treated with 10 milligrams (mg) intravenous (IV) of Valium and 8 mg of Ativan IV with improvement. The patient had symptoms of nausea and emesis. There were also headaches, chills, tremors, dizziness, and diaphoresis. Vital signs demonstrated blood pressure 155/100, pulse 132, temperature 96.7Fahrenheit, respiratory rate 19 and oxygen(O2) saturation 97%. Physical exam showed mild distress but no altered mental status. There were mild tremors. Glucose was 106 with carbon dioxide (CO2) 21.6. alanine aminotransferase (ALT) was 68 with aspartate aminotransferase (AST) 92. Platelets were 82,000 with white blood cell count 4.3. The patient was treated with thiamine, folic acid, and multivitamin. Over the course of the hospital stay the patient was treated with a Librium taper and psychiatric consultation was requested. Inpatient rehabilitation was recommended but the patient declined. The patient was also treated for left-hand cellulitis with five day course of antibiotics. The patient's condition improved with the treatments given and was able to be discharged.

Medical necessity of an inpatient hospital admission has been established.
According to Up-to-date, 2020:
"Ambulatory criteria
-Principal indications for medically supervised alcohol withdrawal in an ambulatory setting are:
-A patient with mild symptoms of alcohol withdrawal (The Clinical Institute Withdrawal Assessment for Alcohol-Revised(CIWA-AR) less than 15), or asymptomatic patient with a history of symptoms with past attempts to reduce their drinking.
-No history of delirium tremens or alcohol withdrawal seizures.
-Additional indications for the ambulatory setting include:
-Cognitively intact and motivated to avoid alcohol.
-Ability to take oral medications.
-Ability to commit to near daily medical visits.
-Absence of comorbid medical or psychiatric conditions and/or marked abnormalities on physical examination or laboratory evaluation.
-Additional contraindications - 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
-Fever
-Disorientation
-Drenching sweats
-Severe tachycardia
-Hypertension
-Pregnancy
-Concurrent substance use that could lead to withdrawal symptoms (e.g., benzodiazepines)
-Markedly abnormal laboratory values".
Based on CIWA scoring greater than 15 with symptoms, the patient did not have a mild case of alcohol withdrawal. Additionally the patient would be contraindicated for ambulatory detoxification and by medical literature criteria the patient would have needed to be monitored in the inpatient setting for medically supervised withdrawal because of sweats, severe tachycardia, and his hypertension.