Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol poisoning.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

This patient is a male who was admitted to inpatient level services for the treatment of alcohol poisoning. The patient was brought to the emergency department by emergency medical services after a fall with a facial injury. He presented with fluctuating levels of consciousness and motor agitation requiring respiratory ventilation and supportive measures. There were no acute general medical or psychiatric issues in this case. Laboratory assessment had shown a blood alcohol level of 382 in the context of a diagnosis of alcohol intoxication and poisoning, thus prompting the decision for intubation, sedation, and ventilation with inpatient admission.

The patient was admitted and placed on telemetry monitoring with supportive measures and ventilation. He was weaned from the ventilator after eight hours with subsequent assessments showing stable vital signs with discharge from hospital care with clinically appropriate follow-up and recommendations. There were no complications during the hospital course, and the patient was discharged in satisfactory condition.

The denial determination was based on Milliman Care Guidelines (MCG) and the plan definition of medical necessity indicating that the patient could have been managed with lower-level care such as observation level.

The appeal is based on the clinical features of the case and the clinical judgment of the treating physicians.

The issue under review is the acute inpatient hospital treatment.

Yes, the proposed treatment was medically necessary for this patient.
The requested benefit of the acute inpatient stay could not have been safely or effectively provided with lower-level services. The patient presented with an accidental overdose of alcohol or alcohol poisoning with intoxication and associated facial injury. He needed an emergency evaluation and treatment with supportive measures and mechanical ventilation and sedation with monitoring that warranted inpatient level care and services. Moreover, the patient's clinical symptoms were serious enough to warrant inpatient level treatment or monitoring. The patient's medical needs could not have been addressed in the emergency department with observation, as the health plan asserts. The clinical judgment with inpatient hospitalization and clinically appropriate treatment after stabilization in the emergency department including observation and supportive measures were entirely appropriate, reasonable, and in the patient's best interest. Thus, medical necessity is met in this case for the requested benefit of the acute inpatient stay in keeping with prevailing standards of professional practice and New York State instruction for this case, as well as the scientific literature and guidelines, referenced below.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
As noted above, the patient's clinical symptoms were serious enough to warrant inpatient-level treatment or monitoring. The patient's medical needs could not have been addressed in the emergency department with observation, as the health plan asserts. The clinical judgment with inpatient hospitalization and clinically appropriate treatment after stabilization in the emergency department including observation and supportive measures were entirely appropriate, reasonable, and in the patient's best interest.