Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Confusion/Alcohol withdrawal
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history including hypertension (HTN), anemia and alcohol abuse who was recently admitted and discharged for anemia.  The patient presented with confusion, gait instability, tremor and urinary retention.  The son believes the patient was drinking.  

Vital signs included: temperature 99.1, heart rate 78, respiratory rate 20, and blood pressure 121/68.  Clinical Institute Withdrawal Assessment (CIWA) was at a four.  Exam was remarkable for psychomotor slowing; coarse tremor; and cervical and lumbar spine tenderness.  Labs revealed the following: white blood cell (WBC) 5.8, hemoglobin/hematocrit (H/H) 9.6/32.6, platelets (PLT) 103, sodium (Na) 138, potassium (K) 4.1, carbon dioxide (CO2) 22, blood urea nitrogen (BUN)/creatinine (Cr) 26/.8, alanine aminotransferase (ALT) 15, aspartate aminotransferase (AST) 43, alkaline phosphatase 130, and total bilirubin 2.5.  Venous blood gas (VBG) showed 7.4/35/26/22.  Flu was negative.  The patient's prothrombin time (PT) was 18.9 and partial thromboplastin time (PTT) was 63.4.  Alcohol (EtOH) was 14, and magnesium (MG) was 1.8.  Head computed tomography (CT) showed no acute disease (NAD).  The patient's chest x-ray (CXR) showed no acute disease (NAD).  Computed tomography (CT) of the cervical and lumbar spine showed no acute disease (NAD).  The patient's electrocardiogram (EKG) revealed atrial fibrillation (A fib).  

The patient was admitted with alcohol withdrawal and Wernicke's encephalopathy.  The Clinical Institute Withdrawal Assessment (CIWA) was at four.  The patient did not require Ativan overnight.  She continued with intravenous fluids (IVF) and oral (PO) Ativan.  She was given lactulose for hyperammonemia.  The patient's hemoglobin (Hgb) was 9.1.  She complained of bright red blood in her stools.  She refused a rectal exam.  She was continued on the current management.  Hemoglobin (Hgb) was 8.2, from 9.1.  She had bright red blood in stools.  She continued the current management.  There was possible esophagogastroduodenoscopy (EGD)/colonoscopy.  She was refusing psychiatry evaluation.  Hemoglobin (Hgb) was 8.9.  Plan for endoscopy.  Endoscopy showed esophageal varicose, erosive gastritis.  Protonix was started.  Hemoglobin (Hgb) was stable at 8.9.  The patient was cleared for discharge.  The patient was pending placement to rehab.  

No, the proposed inpatient admission was not medically necessary.

This patient, with a history of alcohol abuse and recent admission for anemia, was admitted after resuming alcohol consumption and presenting with confusion and gait instability.  The patient was admitted for alcohol withdrawal.  The patient was hemodynamically stable and afebrile.  She did not have tachycardia, vomiting, delirium, seizures, or other marked findings of alcohol withdrawal.  Labs were remarkable for mild anemia.  The patient remained hemodynamically stable during hospital stay without severe alcohol withdrawal.  The patient did not require high doses of Ativan.  The remainder of the hospital stay is remarkable for work up of blood in stools.  Hemoglobin (Hgb) remained stable.  The patient did not have symptoms of alcohol withdrawal or gastrointestinal (GI) bleed that required an acute inpatient level of care.  She had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely.