CLINICAL SUMMARY:
A 34-year-old patient arrived in the emergency department (ED) experiencing complications from alcohol withdrawal, which began while staying at a sober living home. He began experiencing lightheadedness, nausea, vomiting and epigastric pain in addition to developing a bilateral rash to his upper extremities and was transported to the ED. The patient reported drinking one pint of vodka daily for the past two weeks, with the last drink being two days prior to arriving at the ED. His past medical history included alcohol withdrawal seizures and alcohol-induced thrombocytopenia, ADHD, alcoholic hepatitis, anxiety, depression, alcohol use disorder, QTc prolongation, chronic anemia, nicotine use disorder.
Upon arrival, the patient was intermittently tachycardic (>100×6) and tachypneic (>20×4). His lab work showed the following: LFTs showed AST 51 otherwise WNL, magnesium 1.5, ethanol level non-detected, lipase 84, hemoglobin 13.9, platelets 135 and lactic acid normal. An EKG showed a sinus rhythm with a QTc of 481. The ED physician treated the patient with IV sodium chloride, folic acid, thiamine, magnesium sulfate and Ativan 2mg, then subsequently began the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. A benzodiazepine taper was also initiated, with continued monitoring for signs of acute alcohol withdrawal. Concerned about scabies causing the rash, doctors began permethrin for treatment and discontinued triamcinolone cream when the patient showed improvement.
The hospital received payer approval for a four-day inpatient admission. The patient continued receiving oral Ativan as needed in addition to the benzodiazepine taper. He developed further withdrawal symptoms following completion of the benzodiazepine taper with CIWA scores up to 14, therefore doctors extended the benzodiazepine taper for an additional day. The discharge plan was to release the patient to a sober living facility following hospitalization.
However, on the fourth day of admission, the patient developed diplopia and remained hospitalized. Not a typical symptom of alcohol withdrawal, doctors were concerned for Wernicke’s encephalopathy and treated with oral thiamine. The condition worsened the next day. Doctors ordered a head CT but found no acute intracranial abnormality. The patient did show an elevated prolactin level. The brain MRI was unremarkable for pituitary tumor but did reveal vascular abnormality. On the seventh day of hospitalization, the patient’s rash worsened, causing additional treatments and oral diphenhydramine, which resolved the issue. The patient continued to have significant anxiety during hospitalization, including concerns for housing and his financial stability. He also reported an inability to sleep more than a few hours which doctors treated with an increased sertraline dosing and quetiapine nightly. The patient was then discharged with a pending return to the sober living home.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe patient’s Medicaid Managed Care Organization (MCO) plan approved the first four inpatient level of care (LOC) days but denied the second half of the hospitalization due to a lack of medical necessity. The denial letter stated the patient completed the targeted treatment and that withdrawal symptoms improved, so the patient was medically stable to continue treatment at a lower LOC. The decision, according to the denial letter, was based on health plan rules and InterQual criteria.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor completed a peer-to-peer discussion regarding the hospital inpatient admission denial. The physician advisor explained that the patient was admitted for alcohol withdrawal and placed on a benzodiazepine taper following CIWA protocol which was completed after five days. The physician advisor also highlighted that the payer overlooked the ongoing workup of the patient’s new-onset double vision, which began on the fifth day of the patient’s admission. This qualified as a new-onset neurologic condition and therefore a new diagnosis. The Medicaid MCO medical director agreed with the analysis, overturned the denial and allowed the inpatient LOC reimbursement.