Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal Syndrome, Transaminitis
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient has a past medical history significant for alcoholism, hypertension, tobacco abuse, opioid abuse on Suboxone, and depression who presented to the emergency department with complaints of feeling "I'm going to explode." Reportedly, he reported shaking in his hands and the entire body, lightheadedness, left lower quadrant pain with nausea, vomiting. He also complained of some palpitations. The review of systems was positive for diarrhea for 2 months, blood in the vomitus. The rest of the review of systems was negative.
Reportedly, the patient was previously seen in the emergency department for similar symptoms and was admitted to a psychiatric facility because of a major depressive disorder that was associated with suicidal ideations. When the patient was seen by the admitting physician, he was afebrile, heart rate was 60 beats per minute (bpm), respiratory rate 16 breaths/minute, blood pressure 156/94, and oxygen saturation 98% on room air.
The patient was a well-developed, well-nourished, and well-groomed male who was diaphoretic and had tremors in his hands. He looked anxious. His head, eyes, ears, neck, throat (HEENT) exam was within normal limits. He had dry oral mucosa. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound.
The neurological exam was unremarkable except for the tremor in the hands. The rest of the physical exam was within normal limits.

The patient was admitted to the hospital with a diagnosis of alcohol withdrawal syndrome, alcohol intoxication, and transaminitis. Other admitting diagnoses included opioid abuse, tobacco abuse, and hypertension. In the hospital, the patient was seen by a psychiatrist who suggested that there were no indications for psychiatric hospitalization.
During the hospital stay the patient was monitored closely and given medications based on Clinical Institute Withdrawal Assessment (CIWA) protocol. Since his clinical condition improved, he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

Yes, the inpatient stay was medically necessary. Medically supervised alcohol withdrawal is indicated for patients with or at risk of withdrawal symptoms. For patients with mild symptoms and no history of seizures or delirium tremens, supervised withdrawal can be managed safely and effectively in the ambulatory setting.
Patients with more severe symptoms and/or at risk of delirium tremens, seizures, or hallucinations require closer monitoring and intervention, typically in an inpatient setting.
Additional circumstances prompt medically supervised withdrawal in an inpatient setting, llowing for more careful monitoring and more aggressive treatment. These include:
Fever
Disorientation
Drenching sweats
Severe tachycardia
Hypertension
Pregnancy
Concurrent substance use that could lead to withdrawal symptoms (eg, benzodiazepines)
Markedly abnormal laboratory values

In this clinical case, the patient had a history of multiple substance abuse and was at risk of withdrawal from opioids. It was clearly indicated that he had hypertension. He had moderate alcohol withdrawal symptoms since his Clinical Institute Withdrawal Assessment (CIWA) score was documented at 16. In addition, the patient had significant risk factors for developing delirium tremens (DTs).
Taking into consideration all of this information, the admission at the acute inpatient level of care was medically necessary. The admission to the acute inpatient level of care was justified since the patient had moderate alcohol withdrawal symptoms (CIWA score of 16) in addition to multiple medical conditions including hypertension and polysubstance abuse that would increase the severity of withdrawal.
In addition, the patient had significant risk factors to develop DTs. Therefore, he required very close monitoring, and administration of medications in a timely manner to treat his alcohol withdrawal symptoms, prevent dehydration, as well as prevent DTs. This kind of care could be provided in the most effective way at the inpatient level.