Appeal type: Medical necessity
Decision: Upheld

 Substance Abuse
Inpatient Hospital 

This is the case of a female with past medical history significant for chronic back pain with spinal stimulator in place, polysubstance use, Hepatitis C, and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with chief complaint of abdominal cramping, nausea, vomiting, and chills in the setting of recently being taken off Oxycontin and concern for opioid withdrawal. She had taken 24 milligrams (mg) of Suboxone and 20 mg of Oxycontin just prior to presentation.
On presentation, she was afebrile with systolic blood pressure (SBP) 146-191, heart rate (HR) 80s, respiratory rate (RR) 16-18, with oxygen saturation of 100% on room air (RA). Exam otherwise noted the patient to be alert and oriented x 3 with pupils that were dilated. Labs showed complete blood count (CBC) and basic metabolic panel (BMP) within normal limits. electrocardiogram (EKG) did not show significant arrhythmia, ischemia, or prolonged intervals. In the ED, she received normal saline, Ativan, clonidine, Toradol and Zofran. She was subsequently brought into the hospital with assessment that she had opioid withdrawal.
At the time she was seen by the hospitalist, she endorsed weakness and nausea and denied headache (HA), fevers, chest pain (CP), palpitations, shortness of breath (SOB), abdominal pain or other complaints. Vitals noted temp 37, BP 146/73, HR 89, RR 16, sating 100% and she was noted to otherwise be comfortable, alert and oriented, and with bilateral pupil dilation and left posterior lateral hip pain. The plan was to consult pain management, and start intravenous fluids (IVF), Suboxone, Lidocaine, Robaxin, and Zofran as needed (prn) nausea.
She was seen by pain management with assessment that she was comfortable appearing and recommendation for psych consult and continuing current therapies.
The patient was anxious with back pain improved. She denied nausea, vomiting, diarrhea, or other complaints. She continued to be alert and oriented. She was seen by the pain medicine service in follow up and noted to have back pain without noted withdrawal symptoms and with plan for scheduled Robaxin/Neurontin, scheduled Suboxone, bowel regimen, incentive spirometry, and physical therapy (PT). Prior therapy of Suboxone, Tylenol, Toradol and Lidocaine patch were continued.
The patient was ultimately discharged. The issue in question is whether care at the acute inpatient level of care was medically necessary.

The health plan's determination is upheld.

This patient presented with abdominal pain, back pain, nausea and vomiting and history and exam consistent with opioid withdrawal given recent discontinuation of opioids as well as dilated pupils. She was not noted to have altered mental status, diarrhea contributing to electrolyte abnormalities, or to be severely withdrawing from other substances such as alcohol or other medications. As noted above, she had improved on Suboxone. Given she had taken 24mg of Suboxone in addition to Oxycontin prior to coming to the ED, she was certainly appropriate for monitoring, but in the absence of altered mental status, diarrhea causing electrolyte abnormalities, severe uncontrolled hypertension (HTN), or other acute process requiring inpatient admission, it is unclear why care at the acute inpatient level of care was medically necessary. The patient could have been treated at a lower level of care status, which would have been appropriate, and acute inpatient care was not medically necessary.