P2P Review for Denied Inpatient Stay

Case Study: Alcohol withdrawal inpatient stay denial overturned based on care required

Alcohol withdrawal and a positive COVID infection resulted in an inpatient hospital stay for one patient; however, the insurance company denied the short stay. A detailed peer-to-peer discussion of this case with the insurance company overturned the denial based on the acute symptoms and the medical and supportive care required.

CLINICAL SUMMARY: Alcohol Withdrawal

A 19-year-old patient arrived in the emergency room with alcohol withdrawal symptoms and subsequently tested positive for COVID-19. The patient had a past medical history that included anxiety, depression, alcohol withdrawal seizures, hallucinations, alcohol abuse and dependence, and hypertension. He reported passive suicidal ideations without a plan. The patient, who reportedly drank about a liter of whiskey a day, was seeking an alcohol detox program and had a history of delirium tremens. Lab results showed an ETHO breath test of 0.138 and Clinical Institute Withdrawal Assessment (CIWA) 3-23 with additional lab results that showed the following: sodium 134, potassium 4.1, creatinine 0.74, magnesium 2.1, ALT 205, AST 147, total bili 0.8, lipase 160, white count 4.2, hemoglobin 17.4, and platelets 181. Urine drug screen was negative. The patient was treated with the CIWA protocol (Serax tapering dose of benzodiazepine) and also received Haldol.

The patient continued treatment on the second day in the hospital with continued Haldol as well as fall precautions, seizure precautions and telemetry monitoring. The patient left the hospital on day 3 against medical advice.


DENIED INPATIENT STAY

The insurance company initially denied the inpatient stay saying the services could have been provided in an observation (outpatient) setting. The denial stated that records did show that medications and fluids were given by vein but that there was no bleeding, liver problems, low blood pressure, clotting, need for surgery and no kidney or heart problems.

 

PEER-TO-PEER DISCUSSION

A peer-to-peer discussion was completed between AppriseMD and the insurance company’s doctor regarding this case and the denial was rescinded. An inpatient level of care was approved. The discussion centered around the 19-year-old patient’s history of acute alcohol withdrawal, passive suicidal ideation and the incidental COVID positive test. AppriseMD showed that the significant ETOH withdrawal symptoms and agitation required Haldol, IV and PO Ativan and Serax and supportive care. Upon further review, the insurance company agreed and overturned the denial.

OUTCOME: DENIAL OVERTURNED

 

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