Diagnosis: Substance Abuse/Addiction.
Treatment: Inpatient Hospital.
The insurer denied Inpatient stay.
The denial is upheld.

The patient is a male with no significant past medical history who presented to the hospital seeking detoxification from alcohol. The patient stated that he had been drinking heavily for 5 years and consumed approximately 1 pint of liquor daily. The patient had never been hospitalized previously due to alcohol-related problems but was seen in the emergency department for evaluation of chest pain when he was intoxicated. At the time of admission, the patient estimated that his last drink was approximately 36 hours before he came to the hospital.
When seen by the admitting physician he complained of nausea, tremors, abdominal cramping, lower extremity numbness and tingling, mild anxiety, and mild psychomotor agitation as well as occasional sweating.
At the same time, the patient denied fever, chills, headaches, chest pain, shortness of breath, hallucinations, suicidal ideation (SI)/homicidal ideation (HI). In the emergency department, the patient received treatment with Librium, potassium, and magnesium supplements.
When seen by the admitting physician he was afebrile. His pulse rate was 100 beats per minute (bpm), respiratory rate 18 breaths/min, and blood pressure was 153/116.

The patient was admitted to the hospital with a diagnosis of alcohol dependence with withdrawal. CIWA (Clinical Institute Withdrawal Assessment Alcohol) protocol was initiated utilizing Ativan, multivitamins, thiamine, folic acid, and B12. He was evaluated by physical medicine and rehabilitation (PM&R) service for ataxic gait. During the hospital stay his clinical condition gradually improved. Therefore, he was discharged home with a recommendation to abstain from alcohol. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
This patient had relatively mild symptoms of alcohol withdrawal. Even though his heart rate was greater than 100 bpm, there was no evidence of persistent nausea, vomiting, tremor, or increased perspiration in conjunction with other high-risk features such as a history of delirium due to alcohol withdrawal. There were no reported seizures.
Furthermore, there was no history of significant medical conditions such as severe cardiac disease or any other unstable clinical conditions due to alcohol withdrawal.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of services provided required admission at the acute inpatient level of care.
Overall, he remained in stable clinical condition and his alcohol withdrawal symptoms were relatively mild.
There were no unstable medical conditions requiring evaluation or treatment at the acute inpatient level of care.
The hospital stay could have been managed at a lower level of care status.