Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug withdrawal.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

This is an appeal for denial of coverage of acute inpatient stay.  The inpatient stay was denied because it was not supported by Milliman Care Guidelines (MCG), Substance-Related Disorders criteria.  

This male has a history including polysubstance use, bipolar disorder, anxiety, depression and attention deficit hyperactivity disorder (ADHD).  The patient presented to the emergency department (ED) with the complaint of withdrawing form opiates and benzodiazepines. Vital signs revealed the following: temperature 98.6, heart rate 101, respiratory rate 20, blood pressure 145/76, and Clinical Opiate Withdrawal Scale (COWS) 13.  Exam was remarkable for being anxious.  Labs revealed: white blood cells (WBC) 6.2, hemoglobin/hematocrit (H/H) 9.9/32.5, platelets 286, sodium (Na) 137, potassium (K) 3.4, and blood urea nitrogen (BUN) / creatinine (Cr) 14/.9.  Urine toxicology was positive for amphetamine/methamphetamine and opioids.  Electrocardiogram (EKG) showed normal sinus rhythm (NSR).  The patient was admitted with benzodiazepine and opioid withdrawal.  Plan of care included Clinical Opiate Withdrawal Scale (COWS) monitoring, Ativan as needed (PRN), and methadone.  Per psychiatry consultation, the patient was started on Wellbutrin and gabapentin. The patient was not in distress. The patient was cleared by psychiatry for discharge.  Vital signs were stable.  The patient was not in distress.  The patient had no skilled care needs.  He had been accepted another facility; the patient needs a negative COVID test. The patient left against medical advice (AMA).

No, the proposed inpatient admission was not medically necessary.

Medically necessary services are those which are:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice.

This patient has a history of polysubstance use and was admitted for opiate and benzodiazepine withdrawal.  The patient was hemodynamically stable and afebrile.  He did not have an arrhythmia. He did not have nausea, vomiting, tremor or perspiration.  There were no physical signs of withdrawal.  Labs were remarkable for positive urine toxicology.  He did not have comorbid conditions.  The patent was admitted with plan of clinical opiate withdrawal scale (COWS) protocol and management with methadone. The patient was cleared for discharge by psychiatry.  Discharge was delayed pending placement.  The patient remained hemodynamically stabled during hospital stay and did not have signs or withdrawal.  The patient signed out against medical advice (AMA).  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.