Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male who presented to an emergency department, referred from a medical detox facility with poly-substance use disorder and acute psychosis with auditory hallucinations (delirium). The medical screening revealed evidence for rhabdomyolysis and elevated creatinine kinase, as well as electrolyte abnormalities with low magnesium and elevated potassium. The patient had a recent episode of acute kidney injury with rhabdomyolysis and associated hepatic injury requiring a prolonged hospitalization. The examination revealed withdrawal symptoms including shaking, tremors, headache, body aches and restlessness with anxiety. He had auditory hallucinations and dysphoric mood. Electrocardiogram (EKG), computed tomography (CT) scan of the abdomen and pelvis, and chest x-ray were unremarkable. Troponin analysis was elevated and consistent with non-ST-elevation myocardial infarction (NSTEMI) type 2 requiring treatment with aspirin (ASA) and monitoring. The patient was also anemic with elevated platelets reflecting malnutrition. The patient has a history of psychiatric disorder, and history of suicidal or self-harming behaviors with an intentional overdose and hospitalization last year. He was diagnosed with major depressive disorder (bipolar disorder) and attention deficit hyperactivity disorder (ADHD). Substance abuse included cannabis, cocaine, and alcohol, as well as intermittent use of opioids (heroin and Fentanyl) and methamphetamine. He was nicotine dependent with vaping. The patient is single and employed as a tattoo artist and lives with his mother. There were reported legal issues including incarceration for ten years after discharge from the Air Force with five years of service. He denied trauma history. The patient was evaluated in the emergency department and admitted for inpatient treatment with management of the rhabdomyolysis, and supportive measures, and psychiatric consultation recommending referral for rehabilitation treatment and switch from Abilify to Seroquel. 
The patient's hospital course progressed with mild tremors, anxiety, restlessness, and insomnia with persistently mild symptoms of withdrawal and muscle aches that diminished throughout his brief hospital course. The patient stabilized and arrangements were being made for a referral to rehabilitation substance use disorder treatment which the patient declined, and outpatient follow up with disposition to his home in the community. He was discharged against medical advice with recommendations for clinically appropriate aftercare which was arranged. 

The requested health services and treatment, inpatient hospital level care, was medically necessary for this patient.

The requested benefit of inpatient admission for medical services to address rhabdomyolysis and complications of poly-substance use disorder was warranted in this case scenario. The patient in this case was using large quantities of substances including stimulants, cannabis, opioids and alcohol with a presentation and history that did warrant the admission and the continued inpatient level management and monitoring together with supportive measures to manage the rhabdomyolysis. Inpatient hospital level care and medical services, as necessary, and other treatments could not have been safely or effectively provided at a lower level of care. Medical necessity is met in this case, consistent with prevailing standards of professional practice, published guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as New York State instruction for this review and the application of New York Office of Alcoholism and Substance Abuse Services 
(OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.