Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid Overdose
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult male who was brought into the emergency department by emergency medical services after being found unresponsive by his girlfriend who called 911. Upon arrival by Emergency Medical Services (EMS), and in the emergency department, the patient evaluation revealed evidence of a drug overdose and intoxication with pinpoint pupils and respirations of 10 with oxygen (O2) levels of 80 percent and tachycardia; the patient responded to treatment with Narcan with increased respirations to 16 and oxygen levels at 100 percent. Upon arousal, the patient was confused with slurred speech with motor agitation and attempt to elope requiring police intervention. Evaluation revealed elevated liver functions, blood urea nitrogen (BUN) and creatinine, creatine phosphokinase (CPK) and Troponins reflecting organ damage. Drug screen was positive for cocaine and methadone, and the patient admitted to binge drinking alcohol the night before his presentation and apparent overdose. The patient was admitted to acute inpatient level care in order to address the impact of the opioid overdose and organ toxicity resulting from the substance use disorders with opioid, alcohol, and stimulant (cocaine) class substances. The patient had a history of one prior overdose. Treatment included cardio-respiratory monitoring, as well as ongoing evaluation to address the liver and renal toxicity and concern for rhabdomyolysis or myocardial infarction. He received fluid replacement and buprenorphine along with the supportive measures and monitoring. He stabilized and was discharged on Day #4 with clinically appropriate discharge instructions and follow up.
The denial was on the basis of Milliman Care Guidelines (MCG) Health Guidelines pertaining to Drug Ingestion and Overdose indicating that the patient had no symptoms that warranted 24-hour monitoring at the inpatient level of care suggesting observation as the appropriate level of care.
The appeal was on the basis of clinical features including need for monitoring and ongoing evaluations for potential organ failure or damage with indicated treatments, as well as supportive measures warranting the inpatient level of care.

The proposed treatment was medically necessary for this patient.

As indicated in the appeal and in keeping with the plan guidelines, inpatient level care for opioid overdose for dates of service under review was clinically appropriate and medically necessary for this patient. The need for monitoring and ongoing evaluations for potential organ failure or damage with indicated treatments were warranted with inpatient level monitoring and nursing care, as well as supportive measures and treatment with buprenorphine warranting the inpatient level of care. The patient could not have been effectively managed with lower-level care, especially in view of the toxicity to multiple organs and need for monitoring and maintaining the patient who was at risk for serious complications from the intoxication and overdose in the context of poly-substance use with alcohol, cocaine and opioid substances. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews.