Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.  The denial is upheld. 

This is a female patient with a history of bipolar disorder, asthma, depression, anxiety, and noncompliance with medications, history of benzodiazepine overdose, hypertension, hyperlipidemia, seizure disorder, migraines, hyponatremia, and optic neuritis, who presented via ambulance for altered behavior.  The patient presented with complaints of abdominal pain 6 out of 10, in severity that had started several days prior to presentation.  The patient's initial ER vital signs were: blood pressure 137/49, pulse 82, respirations 16, temperature 36.5C, and blood oxygen level 99% on room air.  The patient's proxy reported that the patient was on Librium for Klonopin withdrawal.  The patient's bloodwork revealed sodium 135, chloride 96, white blood cell (WBC) count 3.89, lactate 1.0, lipase 13, and normal liver function tests.  In the ER she was treated with intravenous (IV) fluids, pantoprazole, and metoclopramide.  The patient was admitted for intractable abdominal pain and possible benzodiazepine overdose.  The patient's abdominal x-ray showed a large amount of retained stool throughout the colon; no bowel obstruction or pneumoperitoneum; linear radiopacities in the left abdomen could represent foreign bodies.  The patient's computed tomography (CT) scan of the abdomen and pelvis showed no evidence for bowel obstruction, with large amount of stool throughout the colon.  The patient was given supportive care, Miralax for constipation, home medications for her bipolar and hypertension.  The patient was discharged after two days of hospitalization with plan to continue substance abuse treatment in her community as outpatient.

Based on the review of the medical record, the patient's care in the hospital could have been conducted as outpatient.  As per the documents and vital signs, the patient might have had a therapeutic overdose of benzopdiazepine and not a massive overdose.  For example, the patient might have taken an extra Librium on the day of this hospital presentation. On exam, the patient was not obtunded or in a coma.  Also, the patient did not have any abnormal vital signs, such as low respiratory rate (RR), hypoxia, or tachycardia.  The patient's heart rate was in the 80s, and her blood pressure (BP) was 130s/80s.  The patient did not have any pupillary constriction or dilation.  In other words, there was no "toxidromes" that could pinpoint to any particular toxin.  The patient's mental status could be representative of chronic mental status changes rather
than acute.

Also the patient's basic metabolic panel (BMP) did not show acidosis or any significant
abnormalities of electrolytes.  The patient's lactate was less than 2.  Over the hospital course, there was no worsening of clinical status, chest x-ray, abdominal CT scan, or complete blood count (CBC).  The patient's comprehensive metabolic panel (CMP) was almost all within normal limits (WNL).  Reassuringly, the patient did not have lithium toxicity.  The patient's urine toxicology was positive for benzodiazepines and cannabinoids; cannabinoids could have been a false positive from her numerous other medications.  There was no need to escalate any therapy to positive pressure ventilation or any need for antidotes.  The patient's care could have been safely provided at the observational level of care.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.