Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction/Alcohol Abuse/Addiction/Detoxification from Alcohol
Treatment: Inpatient admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is overturned.

This case involves a woman who came into the emergency department complaining of detoxification. It is unclear what is meant by this chief complaint, but it appears the patient is chronically alcohol dependent, and was experiencing anxiety and withdrawal symptoms. The patient reported nausea, agitation dizziness and diaphoresis as well as palpitations and shaking. At baseline, the patient drank a 12 pack of beers per day, with the last alcoholic beverage the day before presentation. The vital signs on presentation included a temperature of 98(degrees) F (Fahrenheit), a heart rate of 112 beats per minute (bpm), and a blood pressure of 143/113 millimeters of mercury (mmHg).
On examination, the patient was in no apparent distress per the emergency department (ED) physician, was awake and alert, with appropriate mood and well-nourished. The cardiac exam shows a regular rhythm and tachycardic in nature. The lungs were clear to auscultation. The abdominal and musculoskeletal exam were normal. There were no focal neurologic deficits. From a psychiatric point, the patient's mood appeared anxious, agitated with exaggerated affect.
Laboratory data showed a fairly unremarkable complete blood count (CBC), a urinalysis with negative leukocyte estrace and nitrites. The chemistry panel revealed mild hypokalemia of 3.4 and normal kidney function. The liver function tests were surprisingly unremarkable. The urine toxicology screen was negative for any drugs.
A chest x-ray was performed showing no acute abnormality. The Clinical Institute Withdrawal Assessment (CIWA) scale was calculated at 14, based on nausea vomiting, tremors, sweats, anxiety, agitation and headache.
The ED requested admission to the hospital for alcohol withdrawal with elevated CIWA scale. The medical team started the patient on CIWA protocol, with both scheduled and as needed Ativan, multivitamins, and seizure precautions. Potassium was replenished orally.
The next day the patient appeared improved. There were no overnight events, and the CIWA scale was 1. The patient's main complaint was abdominal pain and cramping due to her menstrual cycle. The vital signs appear fairly stable. The standing CIWA Scale orders remained in place. Social worker assessed the patient, and noted no skilled care needs were identified.

The question is whether the above presentation warranted an inpatient level of care.

I overturn, in full, the health plan's determination of medical necessity.

Yes. Inpatient hospitalization was warranted in this case. Based on the provided documentation, inpatient hospitalization was indicated for this patient. Based on the provided documentation, the patient was in severe alcohol withdrawal, with all of the hallmark symptoms, including visible tremors, tachycardia, diaphoresis, agitated mental status, and an elevated CIWA Scale. Based on the lack of clinical improvement in the emergency department with benzodiazepines, it was a reasonable expectation for the patient to have a prolonged withdrawal course spanning multiple days and exceeding the observation level of care. The medical literature supports an inpatient admission for severe alcohol withdrawal, due to the increased morbidity and mortality associated with this condition. I have included representative articles.