Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hyperlipidemia (HL), hypertension (HTN), and chronic alcohol abuse who was admitted with complaints of (c/o) abdominal and chest pain and denied a history of withdrawal seizures. His vital signs were unremarkable. The physical exam was notable for ill-appearing, abdominal tenderness to palpation (TTP), Clinical Institute Withdrawal Assessment (CIWA) 4. The patient was diagnosed with abdominal pain and uncomplicated alcohol withdrawal and treated with benzodiazepines (BZDs), multivitamin (MV), intravenous fluids (IVF), and CIWA. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abdominal and chest pain and was diagnosed with uncomplicated alcohol withdrawal. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, or immunosuppression. For the alcohol withdrawal, the patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. The patient presented with abdominal pain and mild uncomplicated alcohol withdrawal, was treated and responded to BZDs, MV, IVF, and CIWA, and these interventions could have been safely and appropriately provided at a lower level of care. The patient did not have an elevated risk due to alcohol or sedative withdrawal, severe alcohol withdrawal, or severely complicated opioid withdrawal.