Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal, Tachycardia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for hypertension, hyperlipidemia, transaminitis, and alcohol abuse who presented to the emergency department with complaints of nausea, vomiting, racing heart, restlessness, and anxiousness. The patient reported that his last drink was one day before the presentation. Reportedly, the patient was admitted to the hospital just four days before the day of admission for detox.
The admitting physician stated that at the time of the initial evaluation the Clinical Institute Withdrawal Assessment (CIWA) score was 13.
The review of systems was negative for fever, chills, headache, dizziness, vision changes, chest pain, shortness of breath, tingling, numbness, diarrhea, constipation, or dysuria.
At the time of the initial evaluation, the patient was afebrile. His heart rate was 105 beats per minute (bpm), respiratory rate 20 breaths/minute, blood pressure 143/101, and oxygen saturation 98% on room air.
The patient appeared to be a well-developed, well-nourished individual who was in no acute distress. He had a regular heart rate and rhythm without murmurs, rubs, or gallops. His abdomen was soft, non distended, non-tender, with positive bowel sounds. The patient was awake, alert, and oriented times three.
Laboratory evaluation revealed a white blood cell count of 9.99, hemoglobin 15.7, hematocrit 43.8, and platelets 260. The sodium was 130, potassium 4.8, chloride 100, bicarbonate 22, blood urea nitrogen (BUN) 15, creatinine 1.0, glucose 186. alanine aminotransferase (ALT) was 109, aspartate aminotransferase (AST) 115, alkaline phosphatase 111, total bilirubin 0.8. The urinalysis was unremarkable.
The patient was admitted to the hospital with alcohol withdrawal. CIWA protocol was initiated, and the patient was ordered Ativan, Zofran. The patient was also continued on medications for the treatment of hypertension, hyperlipidemia. During the hospital stay his alcohol withdrawal symptoms subsided.
He remained afebrile and hemodynamically stable, therefore he was transitioned to outpatient care.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records demonstrated that the patient had no signs of significant alcohol withdrawal after his initial CIWA score was 13. Subsequently, his CIWA scores were much lower. Furthermore, the patient's mild tachycardia significantly improved within a short period of time. According to the progress notes, there was no mention of persistent nausea or vomiting, tremors, or increased perspiration.
There was no mention that the patient previously had delirium due to alcohol withdrawal, history of repetitive seizures due to alcohol withdrawal, or epilepsy, or any other chronic conditions that could increase the risk of adverse outcomes.
The review of the medical records demonstrated that after the initial period of stabilization the patient remained in relatively stable clinical condition with very low CIWA scores.
Therefore, there is not overwhelming evidence that the severity of the patient's condition justified admission at the acute inpatient level of care.
Overall, he remained in stable clinical condition. The alcohol withdrawal symptoms were steadily improving. He did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.