Diagnosis: Alcohol Withdrawal syndrome, Metabolic Acidosis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history (PMH) of alcohol abuse with prior withdrawal and was admitted with complaints of (c/o) acute alcohol withdrawal associated with hallucinations, tremors, and possible coffee-ground emesis. Vital signs were notable for a pulse of 125. The physical exam was notable for diffuse abdominal tenderness. Lab work was significant for anion gap metabolic acidosis [AGMA] (bicarbonate 13) and creatinine 3.12 (baseline 3.12). Imaging studies, a right upper quadrant (RUQ) ultrasound (US) showed steatohepatitis, a computed tomography (CT) scan of the head showed no acute intracranial abnormality. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with acute alcohol withdrawal and treated with intravenous fluids (IVF), anti-emetics, Clinical Institute Withdrawal Assessment (CIWA), benzodiazepines (BZDs), and a multi-vitamin. The patient's CIWA was noted to be 22 in ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

Yes, the hospital stay was medically necessary at an acute inpatient level of care.
The patient had a medical history and physical exam clinically concerning for acute alcohol withdrawal in the setting of recent alcohol cessation. This presentation was further compounded by the patient's clinical concern for coffee-ground emesis and the patient's known metabolic acidosis and severe acute kidney injury, and these types of patients are not appropriate for a lower level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, including seizures, delirium tremens, Wernicke-Korsakoff syndrome, or severe metabolic or electrolyte derangements. Overall, this patient could not have been safely treated at a lower level of care.