Diagnosis: Alcohol Abuse/Addiction
Treatment: Inpatient emergency admission
The insurer denied the inpatient emergency admission. The health plan's determination is overturned.

The patient is a male with a medical history of alcohol use disorder and prior pancreatitis. He presented to the emergency department with alcohol intoxication and concern for alcohol withdrawal, epigastric pain, nausea, vomiting, and a fall (he hit his head). Vital signs were unremarkable. His physical examination was notable for epigastric tenderness. Labs showed a low hematocrit of 38.5 percent (%), low sodium of 117 millimoles (mmol)/liter (L), low potassium of 2.8 mmol/L, low chloride of 62 mmol/L, elevated blood urea nitrogen of 27 milligrams (mg)/deciliter (dL), elevated creatinine of 2.2 mg/dL, elevated glucose of 185 mg/dL, increased anion gap of 27 milliequivalents (mEq)/L, elevated aspartate aminotransferase of 195 units (U)/L, elevated alanine aminotransferase of 84 U/L, elevated lactic acid of 7.1 mmol/L, elevated potential hydrogen (pH) of 7.6, elevated ethanol of 235 mg/dL, and positive test for coronavirus 2019 (COVID-19).
A chest x-ray showed no acute findings. A computed tomography scan of the head showed no acute intracranial process. Computed tomography scan of the abdomen and pelvis showed no evidence of acute cryptitis, a small sliding hiatal hernia with mild thickening of the distal esophagus suggesting esophagitis, mild gastroesophageal reflux, and hepatic steatosis.
He was treated with intravenous fluids, ondansetron, famotidine, metoclopramide, potassium, oral folic acid, thiamine, Librium, and multivitamin. He was made nil per os. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He was discharged with a plan for Gastroenterology, Primary Care, and Chemical Dependency follow-up.
At issue is the medical necessity of inpatient emergency admission.

The requested health service/treatment of inpatient emergency admission was medically necessary for this patient.
The patient presented with a significant electrolyte derangement in the setting of alcohol intoxication. There was risk for alcohol withdrawal, as well as complications of severe hyponatremia and hypokalemia including cardiac arrhythmias and death. [1-5] Both close clinical monitoring and telemetry monitoring were warranted, and there was the potential need for frequent administration of intravenous benzodiazepines. [6,7] He was appropriately treated for electrolyte derangement with gradual sodium correction using intravenous fluids and maintained on a CIWA protocol. [1-7] Given the patient's electrolyte abnormalities, the inpatient emergency admission was appropriate. Additionally, he tested positive for COVID-19, increasing the risk for complications. [4,5] His electrolytes became closer to normal and the risk for alcohol withdrawal had decreased; for these reasons, the inpatient level of care is supported until the patient was stable to be treated in the outpatient setting.