Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction 
Treatment: Inpatient stay 

The insurer denied the medical necessity of the inpatient hospital stay. The denial is upheld in whole. 

The patient has a medical history of chronic hepatitis C, hepatic cirrhosis, esophageal varices ligated one year prior, asthma, hypertension, and chronic alcoholism, presented to the emergency department with a request for detoxification from alcohol (last drink was that morning), and reported a productive cough for the past week. Vital signs were notable for elevated blood pressure of 147/72 mm Hg. Physical examination was notable for moderate distress, decreased breath sounds, tachycardia, and nontender abdomen. Labs showed low hemoglobin of 12.6 g/dL and hematocrit of 38.1%, low platelet count of 82 K/uL, elevated aspartate aminotransferase of 356 U/L, elevated alanine aminotransferase of 140 U/L, elevated creatinine kinase of 2203 U/L, troponin I of 0.04 ng/mL, elevated lipase of 94 U/L, international normalized ratio of 1.25, elevated lactic acid of 4.9 mmol/L, and alcohol alcohol level of 232 mg/dL. Hepatitis C viral load was 3,430,000 IU/mL. Electrocardiogram shows sinus tachycardia with left ventricular hypertrophy and T wave abnormality. Chest x-ray showed no acute disease. Computed tomography scan of the abdomen and pelvis showed hepatomegaly and nodular liver contour consistent with cirrhosis, minimal perihepatic ascites, and contracted gallbladder containing calculi and sludge. Patient was treated with intravenous thiamine, lorazepam, ceftriaxone, and azithromycin, and started on Zosyn. The next day the patient was awake and alert but showing signs of alcohol withdrawal, including visible tremor, anxiety, tachycardia, and hypertension; also had a mild headache and nausea, and persistent cough. Gastroenterology consultation: hepatic cirrhosis, esophageal varices, alcoholic liver disease, and thrombocytopenia possibly due to hepatitis C; the recommendations were to order ultrasound of the abdomen, continue pantoprazole and nadolol, quit alcohol, and monitor platelet count. Ultrasound of the abdomen showed hepatomegaly and nodular liver contour consistent with cirrhosis, and minimal perihepatic ascites. Esophagogastroduodenoscopy was cancelled as hemoglobin was stable and fecal occult blood test was negative. Hematology/Oncology consultation concluded that there was elevated alpha-fetoprotein in the setting of chronic hepatitis C as well as chronic thrombocytopenia likely related to cirrhosis and chronic alcohol use, and recommended computed tomography scan of the chest, abdomen, and pelvis, and evaluation of B12, folate, and iron panel. The patient was discharged to rehabilitation. 

The inpatient level of care is not supported. In this case, the patient presented with alcohol intoxication and a productive cough. However, there was no sustained tachycardia or hypotension, and alcohol withdrawal symptoms started and subsided; there was no decompensation of cirrhosis [1-3]. No definite pneumonia was found; per validated risk assessment tools and current medical guidelines, the patient was low-risk (by CURB-65 and Pneumonia Severity Index) and could be stabilized without inpatient status and subsequently managed as an outpatient given lack of complications such as sepsis [4-6]. All of the measures that were undertaken, including monitoring, antibiotic therapy, monitoring of withdrawal, and specialist consultations could have been performed without acute inpatient level of care [1-5].