Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male with a history of polysubstance abuse, including opiates, cannabis, cocaine, and benzodiazepines, maintained on methadone, who was found at a train station sitting in a wheelchair unresponsive. The patient was released from the hospital three days before presentation, having been treated for depression and suicidal ideation. He was supposed to be on Wellbutrin and Zyprexa, as part of the optimization for his depression. Emergency Medical Services (EMS) provided two doses of Narcan, for a total of 1 milligrams (mg), after which the patient woke up. Upon waking up, he denied taking any heroin. He endorsed taking 3 mg of Xanax. He also reported that this might have been a subconscious attempt to end his life. The patient did not pick up the antidepressant medications prescribed on discharge.

On exam, he was sleepy but arousable to voice. End-tidal carbon dioxide (CO2) was ranging between 32 and 38. He was alert and oriented x 3 when questioned. The rest of the exam was unchanged from 3 days before.

The patient was admitted to the hospital, secondary to overdose with benzodiazepine, and likely opiates as he responded to Narcan. The one-to-one sitter was placed for possible suicidal ideation, and psychiatry was consulted. Methadone was placed on hold.

The patient was seen by psychiatry the following day, who noted that he was currently alert, calm, and cooperative. He described cold and hot sweats in the setting of not receiving his methadone. He denied suicidal ideation. He reported taking only 2 Xanax. Vital signs remained stable. The psychiatrist recommended maintaining a 1:1 sitter, due to potential suicidal ideation and deemed the patient not to be cleared from a psychiatric standpoint for discharge. They requested repeat electrocardiogram (EKG) for prolonged QTC. They also requested continuing to hold methadone given the long half-life of this medication.

From a medical standpoint, the laboratory studies improved, potassium decreased down to 3.4. The medical team assessed his lower extremities and noted swelling and ulcer. The patient had known chronic venous stasis changes, with a non-healing left anterior shin ulcer. He was previously evaluated by vascular surgery and deemed not to require any surgical intervention, as well as completed chronic antibiotics without a change in status. The patient was nevertheless started on vancomycin. A repeat lower extremity duplex was obtained, which showed an acute non-occlusive left popliteal deep vein thrombosis (DVT). The patient was started on apixaban.

The patient had no new complaints and was requesting to be discharged the following day, so he could go to the post office. Vital signs remained stable. The liver function tests improved. The patient has been restarted on methadone by this time. Social services offered him placement in a shelter, but he refused. The patient was discharged in stable medical condition. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

The patient was brought into the hospital, secondary to hypersomnolence, which responded to treatment with Narcan. The patient was diagnosed with overdose and a possible suicide attempt. From a medical standpoint, the patient had mild abnormalities, including mild hyperkalemia, and mild rhabdomyolysis, which was not affecting the patient's renal function. The elevated liver enzymes are a product of the patient's hepatocellular disease related to fatty infiltrate and hepatitis C, with contributing factors of likely hypotension, from an overdose. The liver enzymes improved in a short time frame. The other medical problems encountered, such as acute nonocclusive DVT in the lower extremity, did not require inpatient hospitalization. The medical literature recommends acute treatment with an oral anticoagulant at a lower level of care setting.

An admission for monitoring was appropriate to ensure stability before reinitiating treatment with long-acting narcotics. It was reasonable to initiate telemetry monitoring of QTC while restarting the antidepressants, which he was taking three days before this event. After carefully reviewing the medical record, the care could have been provided at a lower level of care status.