Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult male. He was brought by emergency services to the emergency department after he was found unconscious in an apartment building. He was revived with 8 mg (milligrams) of Narcan. He had likely overdosed on Fentanyl, as he described using a white substance that he thought was cocaine. Incidentally, his wife had also used the same drug and reportedly had required ICU (intensive care unit) treatment.

In the emergency department, an evaluation revealed abnormal laboratory findings of transaminitis and leukocytosis reflecting kidney injury with an initial BUN (blood urea nitrogen) of 26 and creatinine of 2.5. He had elevated liver functions and WBC (white blood count) at 20.7 initially, then 13.3. Troponin was initially elevated at 0.499 with subsequent value at 0.198. Chest X-Ray showed bilateral evidence of pneumonitis and/or edema with right greater than left. Cardiology consult was obtained with EKG (electrocardiogram) showing no ischemic changes and an ejection fraction at 45-50% with acute heart failure. Psychiatric consultation was obtained indicating that the patient had no safety concerns such as suicidal ideation with diagnoses of the substance use disorders and recommendation for outpatient treatment. In this regard, the patient had a positive drug screen for cocaine and cannabis consistent with history. He was also using alcohol and tobacco.

The patient was treated in the emergency department with Lasix and Zosyn with IV (intravenous) administration and started on antibiotics to address the provisional diagnosis of pneumonitis. He was admitted for inpatient level monitoring of EKG (electrocardiogram), serial cardiac enzymes, CK (creatine kinase), BMP (basic metabolic panel), CBC (complete blood count), and LFTs (liver function tests), as well as continued use of Zosyn and antibiotics together with vitamin replacement therapy and comfort medications, as well as the availability of nicotine replacement therapy and comfort medications, and oxygen at 3 liters with nasal cannula. COWS (clinical opiate withdrawal scale) monitoring with withdrawal protocol was employed and was not significant.

The inpatient hospital course was generally benign with improving status. Discharge diagnosis was pneumonitis and drug overdose likely due to Fentanyl. He was discharge with recommendations for clinically appropriate follow up per recommendations of the psychiatric and cardiology consultants. He was advised on further treatment as clinically appropriate.

The health plan denied the entire hospital stay on the basis of the plan policy and MCG (Milliman care guidelines) 24th edition guidelines pertaining to drug overdose and inpatient level of care, and health plan documents determining that hospital level care was not necessary. The denial indicated that the patient had no hemodynamic instability, no altered mental status, no arrhythmias, and no respiratory distress, as well as no psychiatric or neurologic signs or symptoms that would have required inpatient hospital level of care.

The treatment facility appealed on the basis that the cardiac monitoring and serial monitoring of laboratory assessments and other assessments of the kidney injury, cardiac status and treatment of the pneumonitis were medically necessary with regard to hospital level care that was provided.

No, the Inpatient admission was not medically necessary.
In this case, the patient could have been effectively treated for the substance use disorders with lower level care following observation and stabilization in the emergency department. The patient's underlying treatment for cocaine, alcohol and cannabis use disorders was amenable to treatment in a less restrictive treatment setting, as indicated by the psychiatric consultant. As the health plan asserts in the denial determination, the patient had no hemodynamic instability, no altered mental status, no arrhythmias, and no respiratory distress, as well as no psychiatric or neurologic signs or symptoms that would have required inpatient hospital level of care. Any indicated cardiac monitoring and serial monitoring of laboratory assessments and other assessments of the kidney injury, cardiac status and treatment of the pneumonitis could have been appropriately managed with observation level care with referral for the underlying substance use disorders.

This answer is consistent with prevailing standards of medical practice and with the scientific literature and published guidelines, referenced below and pertaining the the evaluation and treatment of substance use disorders as in this case, and these answers are in keeping with New York State instruction for this medical necessity review and the application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria, referenced below, as well as the health plan's denial determination-noted below.

The health plan denied the entire hospital stay and reasonably indicated that the patient had no hemodynamic instability, no altered mental status, no arrhythmias, and no respiratory distress, as well as no psychiatric or neurologic signs or symptoms that would have required inpatient hospital level of care.