Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol intoxication, chest pain
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department for concerns of alcohol intoxication. Pertinent history included alcohol abuse, tobacco abuse, hypertension, coronary artery disease, and diabetes mellitus. Initial vital signs revealed a temperature of 98.4 degrees Fahrenheit (F), heart rate (HR) 83, blood pressure (BP) 105/70, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 97% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell count (WBC) of 8.5, hemoglobin (Hgb) 14.4, platelets (Plt) 307, international normalized ratio (INR) 0.9, sodium (Na) 143, potassium (K) 3.7, carbon dioxide (CO2) 25, blood urea nitrogen (BUN) 8.8, creatinine (Cr) 0.7, glucose (Glu) 145, aspartate aminotransferase (AST) 17, alanine aminotransferase (ALT) 23, total bilirubin (Tbil) 0.3, ammonia 24.8, Troponin negative, and alcohol level of 383.0. A urine drug screen was negative. An electrocardiogram (EKG) was without acute ischemic changes. A chest radiograph revealed cardiomegaly without acute cardiopulmonary disease. A computed tomography (CT) scan of the cervical (C)-spine and head were unremarkable. The patient was admitted to the hospital with an impression of alcohol intoxication and chest pain. The admitting physician a couple of hours later had an impression of alcohol withdrawal and acute coronary syndrome ruled out. The treatment plan included intravenous fluids, thiamine, folate, scheduled lorazepam, Clinical Institute Withdrawal Assessment (CIWA) with lorazepam as needed, serial troponins, and an echocardiogram. The patient reported mild withdrawal symptoms. The heart rate was observed up to 104 beats per minute (bpm) and occasional tremors were noted. Multiple CIWA scores by nursing ranged from 7-13. An echocardiogram did not reveal significant abnormalities. The treatment plan was continued. The patient was deemed medically stable for discharge without benzodiazepines.
At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission.
The patient presented with alcohol intoxication and, after a period of time, was believed to have developed an alcohol withdrawal syndrome that consisted of tachycardia up to 104 bpm, muscle tremor, anxiety, slight agitation, and minimal paroxysmal sweating (per documented nursing CIWA). Treatment included lorazepam without issue or complication. Following observation care, the patient was discharged.
Perry et al. note alcohol withdrawal is a common condition encountered in the hospital setting after abrupt discontinuation of alcohol in an alcohol-dependent individual. Patients may present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Management revolves around early identification of at-risk individuals and symptom assessment using a validated tool such as the revised Clinical Institute Withdrawal Assessment for Alcohol score. Benzodiazepines remain the mainstay of treatment and can be administered using a front-loading, fixed-dose, or symptom-triggered approach. Long-acting benzodiazepines such as chlordiazepoxide or diazepam are commonly used and may provide a smoother withdrawal than shorter-acting benzodiazepines. Patients with symptoms refractory to high doses of benzodiazepines may require addition of a rescue medication such as phenobarbital, propofol or dexmedetomidine.[1] In this particular situation, symptom assessment was performed and standard medication therapy was provided.
Jess et al. note the alcohol withdrawal syndrome (AWS) is a dynamic and complex process. For this reason, there have been many attempts to classify symptoms of AWS either by severity or time of onset to facilitate prediction and outcome. In early stages, symptoms usually are restricted to autonomic presentations, tremor, hyperactivity, insomnia, and headache. In minor withdrawal, patients always have intact orientation and are fully conscious. Hallucinations of visual, tactile or auditory qualities, and illusions while conscious are symptoms of moderate withdrawal. They can last up to 6 days. The appearance of acute symptomatic seizures may emerge 6-48 hours after the last drink. Delirium tremens (DT), onset 48-72 hours after cessation of drinking represents characteristics of severe withdrawal that may last for up to 2 weeks.[2] In this particular situation, the patient's alcohol withdrawal syndrome would be classified as mild.
Muncie et al. note outpatient treatment of mild or moderate AWS is generally safe, effective, and less expensive than inpatient treatment, and may allow for less interruption of work and family life. However, patients with serious psychiatric problems (e.g., suicidal ideation, psychosis) or medical conditions should be treated in an inpatient setting. Although routine laboratory tests are unnecessary for patients with mild AWS, significant laboratory abnormalities (e.g., complete blood count, liver function, glucose, or electrolyte testing) would preclude outpatient treatment. Patients with positive results on a urine drug screen, which signifies concurrent drug abuse, should be treated as inpatients. Mild AWS is classified as symptoms of anxiety, tremor, insomnia, headache, palpitations, gastrointestinal disturbances. Moderate AWS is classified as mild symptoms plus diaphoresis, increased systolic blood pressure, tachypnea, tachycardia, confusion, mild hyperthermia. Lastly, severe AWS is classified as moderate symptoms plus disorientation, impaired attention, visual and/or auditory hallucinations, seizures.[3] In this particular situation, the alcohol withdrawal syndrome would be classified as mild plus (+) tachycardia. Thus, outpatient treatment would be considered safe and effective.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have alcohol or sedative withdrawal signs plus high-risk indicators (eg. history of delirium due to alcohol or sedative withdrawal, history of repetitive seizures due to alcohol or sedative withdrawal, Intrinsic seizure disorder (epilepsy), pregnancy, or other significant medical history (eg, severe cardiac disease) that is assessed to be at risk for destabilization due to withdrawal). The patient also did not have severe alcohol or sedative withdrawal that is not manageable at lower level of care such as marked signs of withdrawal plus inadequate response to pharmacotherapy in emergency department or other appropriate lower level of care, lower level of care not feasible or appropriate (eg, unavailable or inappropriate to patient condition or treatment history). Lastly, the patient did not have severe dysfunction in daily living, imminent danger to self, or imminent danger to others.[4]