Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Drug overdose. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity.  The denial was upheld.

The patient is a male with a past medical history significant for polysubstance abuse who was brought to the emergency department after he was found non-responsive. At that time, he had a low respiratory rate and constricted pupils. The patient was given Narcan by Emergency Medical Services (EMS) with initial improvement in his mental status. However, while in the emergency department, the patient remained in an altered mental status for over 10 hours. The emergency department provider spoke on the phone with the patient's girlfriend who said that the patient was recently prescribed 120 pills of Klonopin. Subsequently, 10 pills of Klonopin were found in the bottle.
At the time of the initial evaluation in the emergency department, the patient was afebrile. His blood pressure was 124/77, heart rate was 90 beats per minute (bpm), respiratory rate was t between 10 and 16 breaths/minute, and oxygen saturation was 94% on room air. In the emergency department, the patient remained hemodynamically stable. He was protecting his airway.
His laboratory evaluation revealed a serum sodium at 140, potassium was 4.2, chloride was 109, bicarbonate was 19, blood urea nitrogen (BUN) was 17, creatinine was 0.81, and glucose was 115. His liver function tests were within normal limits. The white blood cell count was 11.0, hemoglobin was 15.0, hematocrit was 41.0, and platelets were 310.
A computed tomography (CT) scan of the head showed no evidence of hemorrhage, mass, or acute infarct. The patient was admitted to the hospital with altered mental status, toxic encephalopathy, possible suicidal ideations, and leukocytosis. The urine toxicology screen came back positive for cannabinoid, benzodiazepines, and opiates.
In the hospital, the patient was seen by a psychiatrist who suggested that the patient did not need 1:1 supervision or any psychotropic medications. Subsequently, the psychiatry service cleared the patient for discharge.

During the hospital stay, the patient's clinical condition normalized, and he was discharged from the hospital in stable clinical condition with a recommendation to follow up with his primary care physician and a psychiatrist as an outpatient.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.  No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.

Based on the nationally accepted standards of care, admission at the acute inpatient level of care in cases of a drug overdose is generally required when a patient with a drug overdose presents with clinical signs of hemodynamic instability, dangerous arrhythmia, the potential for dangerous arrhythmia requiring telemetry monitoring beyond observation care, respiratory abnormalities, hypertension requiring inpatient treatment, severe electrolyte abnormalities, certain specific findings indicating severe, prolonged, or delayed drug toxicity, severe or persistent altered mental status, severe metabolic findings persisting beyond observation period of care, recurrent seizures, psychiatric risk status not acceptable for outpatient management, and other circumstances.

In this clinical case, the patient was hemodynamically stable, his altered mental status improved within a short period of time. The patient was evaluated by a psychiatrist who suggested the patient did not require inpatient psychiatric treatment. The laboratory evaluation did not demonstrate clinically significant abnormalities. Taking this into consideration, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. Overall, the patient remained in stable clinical condition and did not require diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

Therefore, the Inpatient stay was not medically necessary.