The patient is a male with a history of alcohol abuse. He presented to the emergency department requesting admission for alcohol withdrawal. He had a shoulder fracture that had occurred two weeks prior; he was unable to say whether or not this occurred in the setting of a seizure. He complained of tremors and mild nausea.
In the emergency department, his blood pressure was 129/90 millimeters of mercury (mmHg). His heart rate ranged from 101 to 123 beats/minute. On physical exam he was mildly tremulous with tongue fasciculations. His Clinical Institute Withdrawal Assessment (CIWA) score was 8. He was treated with lorazepam and admitted to the hospital. The following day his blood pressure was 159/105 mmHg with a heart rate of 98-103 beats/minute. On exam he was tremulous. His CIWA score was 3-5. On the third day he was hypertensive with a blood pressure of 172/120 mmHg with a heart rate of 89 beats/minute, He had bilateral upper extremity tremors with a CIWA score of 5. His lorazepam was slowly tapered. The following day his CIWA score was 3. Lorazepam taper was continued. On the day of discharge, his tremor had resolved.

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient.
While most patients with acute alcohol withdrawal do not need inpatient admission, given the risk for delirium tremens, which can be fatal, a minority do require inpatient care. The decision regarding inpatient admission should be based on the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA), which includes such factors as nausea, vomiting, tremor, diaphoresis, anxiety, agitation, itching, hallucinations, visual disturbances, headache and disorientation. According to current recommendations, patients with mild symptoms (CIWA score of less than 8) can be monitored on an outpatient basis and may not require medication. Patients with a CIWA score of 15 or higher or a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions should be admitted to the hospital. The decision regarding admission versus outpatient care of patients with scores from 8 to 14 should be individualized. This patient's initial score was 8. While medication and careful outpatient monitoring is often acceptable in this situation, the possible history of a recent alcohol withdrawal seizure and shoulder fracture placed this patient in a higher risk group. Inpatient admission with careful monitoring and serial assessment was reasonable and prudent and supported by the medical literature.