Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches, Dizziness and Hallucinations
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male with diagnosis of chronic alcohol withdrawal symptoms. He was admitted to the inpatient level of care. The history and physical note indicated that the patient initially presented with headache, hallucinations, vomiting, and dizziness for ten days prior to admission, and tremors for two days. He noted that he was a heavy drinker and typically drinks one bottle of vodka and one bottle of beer daily. His last 
drink was two to five days prior to admission. He stated that he had lost consciousness the day before admission due to drinking but denied symptoms indicative of seizure. He noted that he had
not eaten in ten days. The patient has a history of alcohol withdrawal seizures. The patient's vital signs were temperature 98.3, heart rate 78, blood pressure 148/83, respirations 18, 
and oxygen saturation 98% (percent) on room air. CIWA (clinical institute withdrawal assessment) score was 7. The patient was given Librium 25 mg (milligrams) and Versed 5 mg (milligrams) in the ED (emergency department), but he was noted to have continued tremors and unsteady gait. Head CT (computed tomography) was negative for acute abnormalities. The plan was to admit the patient for safe detoxification from alcohol with a diazepam taper. Psychiatry was consulted due to the patient's reports of auditory and visual hallucinations and stated that these symptoms were most likely due to alcohol withdrawal and should resolve. The discharge summary indicates that the patient was discharged against medical advice on the next day. At issue is the inpatient level of care. Coverage was denied by the health plan as not medically necessary because there was no documentation of CIWA (clinical institute withdrawal assessment) scores of 8 or better, no additional risk factors such as positive blood alcohol level, systolic blood pressure greater than 150, and no significant dehydration, persistent vomiting, or altered mental status or seizures. The decision was appealed by the treating facility, who note that the admission was medically necessary due to the patient's alcohol withdrawal symptoms. The decision was upheld by the health plan as not medically necessary because there was no documentation of alcohol withdrawal scores of 8 or greater, no dehydration, and no continuous vomiting, mental state, or seizures. An external review was requested by the treating facility, using the same rationale as previously.

The requested health service was not medically necessary.

The submitted clinical documentation notes that the patient was not experiencing serious symptom of alcohol withdrawal, including autonomic instability, heart rate sustained at greater than 100 beats per minute, systolic blood pressure of greater than 150, seizure activity, or a CIWA (clinical institute withdrawal assessment) score indicative of more than mild withdrawal symptoms. The inpatient level of care is reserved for these symptoms. Review of the medical literature concludes that the use of CIWA (clinical institute withdrawal assessment) scores is accurate in following the course of alcohol withdrawal syndrome, which supports the health plan's decision that the patient's condition did not warrant the inpatient level of care. Kaplan and Saddock also note that the inpatient level of care is only necessary for severe and complicated cases of alcohol withdrawal. The definition of medical necessity generally includes that a treatment or service must be provided in the least restrictive setting as appropriate and safe for the patient's condition, and that the service must be considered effective and appropriate for the treatment of the patient's condition. Since the inpatient level of care does not fit this definition in this case, it was not medically necessary for the patient.