Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol Abuse.
Treatment:  Inpatient Hospital Stay.

The health plan denied the inpatient hospital stay.  The health plan's determination is upheld.

The patient is a  female with a past medical history of hypertension, alcohol abuse, seizures, asthma/ chronic obstructive pulmonary disease (COPD) who presented to the emergency department (ED) with generalized weakness and poor appetite.  There were no reports of chest pain, anxiety, headaches, diaphoresis, dyspnea, fever, cough, abdominal pain, nausea, vomiting, diarrhea, falls, seizures, change in mental status, delirium, auditory /tactile / visual hallucinations or syncope.

Initial vitals were a heart rate (HR) of 73 beats per minute (bpm), a respiratory rate (RR) of 15, T 98.2F., a blood pressure (BP) of 124/71 millimeters of mercury (mmHg)and a peripheral capillary oxygen saturation (SpO2) of 100% on ambient air.  The patient was alert and oriented and was not in acute distress.  There were no shaking, tremors or delirium or change in mental status noted.  Initial labs showed serum alcohol elevated at 305, a white blood cell count (WBC) of 3.4 K, a hemoglobin of 8.7 g/dl, a sodium of 146, a potassium of 3.8, a carbon dioxide (CO2) of 22, a glucose of 148, a blood urea nitrogen (BUN) of 15, a creatinine of 0.8, a low magnesium at 1 mg/dl, a lipase of 4, an aspartate aminotransferase (AST) elevated at 272, and an international normalized ratio (INR) of 1.13.  Troponin level was elevated at 0.082.  An electrocardiogram (EKG) showed normal sinus rhythm (NSR), occasional premature ventricular contractions (PVCs), and no acute ST T wave changes.  Urine toxicology was negative.  A chest x-ray showed no acute pathology.

The patient was hospitalized for an elevated troponin (rule out acute coronary syndrome (ACS)), impending alcohol withdrawal, high anion gap metabolic acidosis, and electrolyte abnormalities.  Troponin levels trended down, and the Clinical Institute Withdrawal Assessment (CIWA) scores were less than 8 during the hospitalization, and the patient did not require Lorazepam.  The patient was referred to an outpatient alcohol cessation program.  After 6 days of hospitalization, the patient was discharged home.  At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

The admission was not medically necessary for acute inpatient level of care.  There were no compelling clinical reasons why the patient could not have been safely and appropriately evaluated and cared for at an alternate level of care.

On admission, the patient did not exhibit signs and symptoms of moderate to severe withdrawal, such as acute mental status change, nausea, vomiting, diarrhea, hallucinations, seizures, extreme tremors, agitation, unstable vital signs that would require inpatient level of care.  The patient did not have acute complications from alcohol abuse, such as acute pancreatitis, acute encephalopathy, acute blood loss / GI (gastrointestinal) bleeding, acute fall / trauma or acute liver failure.  The patient was hemodynamically stable and did not have tachycardia or uncontrolled blood pressure.

The patient did not exhibit extreme behavior change, paranoia, agitation, aggressiveness, mania, or actions /intent posing significant harm to self or others.  CIWA scores were less than 8, and the patient did not require medication for withdrawal.