Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient stay
The insurer denied coverage for inpatient stay
The denial is overturned

This adult male was admitted to this inpatient hospital after a serious fentanyl and heroin overdose. He was found by his family lying on the couch surrounded by emesis and his family gave him Narcan. He was dyspneic, hypoxic, nauseous, coughing, wheezing, and had an elevated heart rate of 130 and elevated blood pressure of 154/93. He was given additional Narcan by emergency medical services (EMS). He still had medical issues and required intravenous (IV) normal saline bolus, IV ondansetron, albuterol nebulizer, and IV methylprednisolone 125 milligram (mg). His medical condition worsened as his oxygen levels decreased to 88% (percent) and he needed oxygen supplementation as he was not responding to emergency department (ED) treatment. He had a history of schizophrenia in addition to IV drug use. He was admitted to telemetry for cardiac monitoring and pulse Ox (oximeter) monitoring and was getting Clinical Institute Withdrawal Assessment for Alcohol (CIWA) assessments for possible opioid withdrawal. He was admitted for drug overdose by IV drug use, systemic inflammatory response syndrome (SIRS) secondary to aspiration pneumonitis and acute hypoxic respiratory failure. He was discharged when he was medically stable. 
     
According to the Milliman Care Guidelines (MCG) for Drug Overdose/Ingestion he met criteria for hospitalization as he had altered mental status initially and had medical consequences to his drug overdose which put him at risk medically and in need of acute hospital treatment. He worsened in his oxygen level and required oxygen supplementation, and he required multiple IV treatments including IV saline, IV ondansetron, albuterol nebulizer, and IV methylprednisolone 125 mg. He required additional Narcan as he had Narcan administered at home and by the EMS. He was dyspneic, hypoxic, nauseous, coughing, wheezing, and had an elevated heart rate of 130 and elevated blood pressure of 154/93 so his vital signs were not stable. He took an overdose of both fentanyl and heroin which put him at high risk for an overdose death. He required cardiac monitoring and pulse oximetry monitoring and CIWA assessments for possible withdrawal due to this serious overdose. He had serious medical issues as it was reported that he was admitted for drug overdose by IV drug use, SIRS secondary to aspiration pneumonitis and acute hypoxic respiratory failure. It was reported that the aspiration pneumonitis was secondary to vomiting after the fentanyl and heroin overdose. This patient was not considered medically stable and he required acute hospital treatment as his serious opiate overdose with fentanyl and heroin resulted in other medical consequences as mentioned above which required inpatient hospital treatment and monitoring. He was at high risk for death from overdose and also at risk for severe withdrawal and he had unstable vitals in addition to the medical issues. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is overturned. Medical Necessity is substantiated.