Alcohol abuse
Substance abuse: inpatient

On presentation to the emergency department, the patient reported past history of acquired immunodeficiency syndrome (AIDS) / human immunodeficiency virus (HIV), high cholesterol, substance abuse, bipolar disorder, diabetes. Vital signs were initially within normal limits with a heart rate of 78. The patient reported drinking "3 pints with some beer." It was unclear from the initial documentation what type of alcoholic drink was quantified by the phrase "3 pints." Patient stated that her last drink had been a few hours prior to coming to the hospital. Patient reported alcohol withdrawal with detoxification some months ago. Patient reported having seizures in the past. There were no initial medical complaints.
Subsequent documentation indicated that the patient was drinking "3-4 pints of liquor daily." Patient reported that her maximum period of sobriety had been 4 months in the past. Also reported a history of seizures and delirium tremens during prior detoxification admissions. Patient also reported a history of heroin, cocaine, and marijuana abuse. Patient reported being sober for more than 20 years, though was unclear from documentation to which substance this referred. Medications included Seroquel, Lexapro, Ambien, Klonopin/Ativan, Truvada, Isentress.
Initial Clinical Institute Withdrawal Assessment (CIWA) score was 13. Patient was admitted for detoxification on an Ativan protocol.
The health plan's determination of medical necessity is overturned in whole. The patient was drinking heavily prior to admission, had a significantly elevated alcohol withdrawal score, and had a history of alcohol withdrawal seizures and delirium tremens and needed inpatient detoxification. The patient did not require immediate hospitalization for life-threatening medical conditions or for a severe psychiatric crisis. Alcohol was the substance most likely to cause harm. The patient clearly met criteria for an alcohol use disorder. The patient was not in full remission from the substance use disorder. The patient was using a substance with the risk of medical complications from withdrawal. The patient did have serious medical symptoms of withdrawal that would require medical management and a hospital setting. Vital signs would need to be monitored at least every 6 hours and likely more. Detoxification medications were needed to prevent or modify withdrawal and the client's needs needed to be monitored to adjust medication. The patient had a history of seizures and delirium tremens and there was a long term history of substance abuse that would eventually lead to serious medical problems.
LOCADTR Level of Care is: Hospital Based Inpatient Detoxification
The patient could not have been safely and effectively treated for withdrawal symptoms at a lower level of care.