Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Withdrawal
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a history of polysubstance abuse on Methadone, HTN (hypertension), HLD (hyperlipidemia), CKD (chronic kidney disease), Hepatitis C, cocaine-induced cardiomyopathy, ICD (implantable cardioverter defibrillator) placement due to torsades with benzodiazepine withdrawal, and withdrawal seizures. He presented to the ED (emergency department) with complaints of palpitations, shakes, anxiety, auditory and visual hallucinations, fatigue and low PO (oral) intake. He had experienced a panic attack in the morning. The patient reports that he was unable to take his medications for anxiety over prior five days. His medications include Xanax, Klonopin, and Ambien.

The patient's vital signs included the following: Temperature 96.6, Pulse 71, respiration rate 15, blood pressure 144/84, and pulse oximetry 98%. The patient's exam was remarkable for irregular heart rhythm, mild tongue fasciculations, and bilateral UE (upper extremity) tremor at rest. The patient's labs were as follows: WBC (white blood count) 13.6, H/H (hemoglobin/hematocrit) 12.5/36.8, Plt (platelets) 184, Na (sodium) 138, K (potassium) 4.7, BUN/Cr (blood urea nitrogen/creatinine) 34/2.48, Glu (glucose) 88. His LFTs (liver function tests) were within normal limits. His CXR (chest x-ray) revealed no active disease. His EKG (electrocardiogram) revealed sinus rhythm with PVCs (premature ventricular contractions) and bigeminy.

The patient was admitted with a diagnosis of benzodiazepine withdrawal. Plan of care included Klonopin taper and CIWA (clinical institute withdrawal assessment) protocol. Cardiology consult noted Methadone associated ventricular ectopy. ICD (implantable cardioverter defibrillator) was noted to be at end of life. There was no indication for replacement. Toprol was discontinued.

Admission day one, the patient's vital signs were stable. The plan was to consult Detox, continue Methadone, place on CIWA (clinical institute withdrawal assessment). The patient declined rehab.

Admission day two, the patient's vital signs were stable. No events were noted overnight. CIWA (clinical institute withdrawal assessment) was not triggering. The patient was to continue Klonopin taper and CIWA (clinical institute withdrawal assessment) protocol, discontinue lorazepam, and consult Detox.

Admission day three, the patient's vital signs were stable. The patient was noted to feel ok. He had no hallucinations in the prior 24 hours. He had no tremors. He was to continue current management and add gabapentin per psych.

Admission day four, the patient's vital signs were stable. Gabapentin was discontinued because it was not tolerated. Addiction medicine adjusted the Klonopin taper.

Admission day five the patient's vital signs were stable. Gabapentin was restarted and tolerated. The plan was for discharge by Sunday.

Admission day six, the patient's vital signs were stable. The patient was concerned about being discharged too soon. The plan was to transfer to psych unit for prolonged detox.

Admission day seven, the patient was discharged to detox.

No, the Inpatient admission 08/21/2020 to 08/28/2020 was not medically necessary.
Medically necessary services are those which are the following:
1)	Safe
2)	Effective
3)	Generally accepted national standard of medical practice
4)	Not provided primarily for convenience of the patient or the practitioner
5)	The least intensive and/or most appropriate alternatives among diagnostic and treatment option

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient, with a history of benzodiazepine dependence and arrhythmia due to benzodiazepine withdrawal, was admitted for benzodiazepine withdrawal after having missed several days of his medications. The patient was hemodynamically stable and afebrile. He had normal oxygenation. He did not have tachycardia. His EKG (electrocardiogram) showed ectopy, but no significant arrhythmia. He had hallucinations but was not determined to be at harm to himself or others. Cardiology did not recommend additional management of ectopic beats. He did not have nausea or vomiting. Tremors and tongue fasciculations were observed. Labs were unremarkable. He did not have comorbid conditions. He was not scoring on CIWA (clinical institute withdrawal assessment). He was admitted and started on Klonopin taper. The patient remained hemodynamically stable during hospital stay without severe withdrawal. He continued to not score on CIWA (clinical institute withdrawal assessment). Klonopin taper was continued with adjustment of medications for anxiety. He was transferred to psych unit for prolonged detox. The patient did not have withdrawal symptoms or receive intervention that required an acute inpatient level of care. In addition, the patient had not failed an observation level of care. The requested inpatient admission was not medically necessary.