Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction 
Treatment: Inpatient Hospital Stay 
The insurer denied inpatient hospital stay. 
The denial is upheld.

The patient is a male with alcoholism, bipolar disorder, and gastritis who presents to the emergency department with complaints of epigastric pain for seven days. The patient endorsed alcohol binge for the past seven days, drinking ten shots of vodka daily. The last alcoholic beverage was on the day of admission. He described the epigastric pain as intermittent, worsened by alcohol, with associated generalized weakness, diaphoresis, leg numbness, and palpitations. In addition, there were several episodes of non-bloody nonbilious emesis, and no food intake was reported in the past ten days. The patient also endorsed tarry stools over the past week.

The principal admitting diagnosis is epigastric pain in the setting of alcoholism. Prior history of endoscopic assessment a few years ago revealed gastritis and grade A esophagitis. The patient was started on intravenous (IV) Protonix. The medical team noted that the patient was tachycardic with hand tremors on the exam and placed him on Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal. A urine toxicology screen was also ordered, and the patient was given thiamine folic acid.

The patient was reassessed the following day and noted CIWA scores of 3 overnight as the highest score, due to mild tremor sweats and anxiety. The rest of the CIWA scores were 1. The patient felt generally weak when walking around, but otherwise did well. The epigastric pain and thigh numbness resolved. He could tolerate food and drinks and had a normal bowel movement. Vital signs appeared stable, with a temperature maximum (T-max) of 99.2, heart rate of 103, and blood pressure 120/78. The exam appeared fairly unremarkable. Repeat labs showed improvement in sodium, potassium, and magnesium levels. The hemoglobin was 13.5. The patient was offered outpatient rehab for alcohol cessation therapy. The medical team planned a discharge with outpatient referrals for gastrointestinal (GI) and psychiatry. He was deemed medically optimized for release on this day.

Inpatient hospitalization is not warranted in this case. Based on the provided documentation, the patient had epigastric pain, with nausea and vomiting, that resolved within 24 hours. There is no evidence of pancreatitis, active GI bleed, bowel obstruction, or intra-abdominal vascular emergency. CIWA scores were low, and the patient did not experience delirium tremens. He was released from the hospital within 24 hours of hospitalization. There is no indication for an inpatient level of care.

The patient had been drinking vodka with associated nausea and vomiting at home based on the provided documentation. He also reported dark, tarry stools, which raised the suspicion of GI bleed. However, hemoglobin was stable, there was no evidence of recurrent bleeding, and had a formed regular bowel movement within 24 hours of hospitalization. He could also tolerate diet advancement within 24 hours of hospitalization and had complete resolution of epigastric pain. From an alcoholism standpoint, the CIWA scores were generally at 1, with the maximum CIWA score at 3. These are relatively low scores, without evidence of severe withdrawal, hallucinations, or delirium tremens. As a result, the patient's condition could have been managed under a lower level of care status.