Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhabdomyolysis.
Treatment: Inpatient hospital admission.

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

This is a male patient with a history of anxiety, post-traumatic stress disorder, schizophrenia, paranoia, substance abuse (methamphetamines), and substance-induced psychosis. The patient was seen in Behavioral Health 1 day prior for meth use and paranoia. He was discharged after evaluation, with arrangements for inpatient admission the next day. The patient's symptoms worsened and he presented to the Emergency Room (ER) via ambulance with anxiety and hallucinations. He denied suicidal and homicidal ideation in the ER, but appeared anxious and refused to sit down. The patient's initial vital signs were: blood pressure 151/84, pulse 133, respirations 20, and temperature 98.9F. He was alert and oriented and denied drug or alcohol use. Bloodwork revealed white blood cell (WBC) count 15.29, carbon dioxide 15, anion gap 27, creatinine 1.32, aspartate aminotransferase (AST) 1536, alanine aminotransferase (ALT) 291, and creatine kinase (CK) greater than 22000. His salicylate, acetaminophen and ethanol levels were normal. The patient was given a dose of Ativan and was admitted with a diagnosis of rhabdomyolysis. Intravenous (IV) fluid hydration was started. He was seen by Behavioral Health and Psychology. The patient coped well with hospitalization. The CO2 level improved and was above 21 meq/L. His urinalysis was clear and reflected no hematuria. The patient had no evidence of worsening rhabdomyolysis nor worsening psychosis. He was on full oral (PO) diet and on room air (RA) for all of his hospitalization. He was later discharged in a stable condition. 

As per the medical records submitted, it is clear that the patient's transient increase in CK was due to methamphetamine toxicity. Methamphetamine toxicity in this patient resolved expectantly with supportive care such as benzodiazepines and intravenous (IV) fluids. Most common acute presentation of methamphetamine toxicity is behavioral and his creatinine was 1.32 initially and the levels trended down. The patient had an EKG showed normal intervals of QRS and QTC hence methamphetamine induced cardiotoxicity is unlikely. His tachycardia from the toxic acute effect resolved with time. The patient also did not require pressors for hemodynamic support. He never developed hypoxia nor required oxygen during the hospitalization. The patient also did not have effect of acute sympathetic surge other than transient elevation of blood pressure (BP) and heart rate (HR). Other toxic effects of amphetamine can be seizures and stroke like episodes which patient did not manifest. His rhabdomyolysis was managed as expectedly with IV fluids and no acute renal failure resulted. If one were to examine the MEWS (modified early warning score) after patient was admitted it would be 0 or 1 which indicates patient was a candidate for observational status; MEWS can be used in the screening of patients whose condition is rapidly declining, in order to check whether transfer to a higher degree of care is required. 

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

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