Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

According to the documentation submitted, this patient has a history of post-traumatic stress disorder, gastritis, constipation, and marijuana abuse. She presented to the emergency room (ER) with complaints of abdominal pain. Imaging of the abdomen revealed a slight prominence of extrahepatic biliary ductal system. In the ER the patient was given intravenous (IV) Protonix, IV morphine, IV Tylenol, IV Toradol, IV Reglan, IV fluids, and Zofran. She was admitted with intractable abdominal pain related to marijuana use. The patient was given around the clock pain medication and IV fluids. Serial abdominal examinations were done. Signs and symptoms were monitored. The patient was discharged after a period of medical stability. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

In this case this patient did not have reports of active severe substance withdrawal symptoms, past complicated withdrawal such as alcohol withdrawal seizures or delirium tremens, and there were no reported acute medical issues requiring only 24-hour hospital treatment then.  The medical records stated that the patient had abdominal pain, small bowel obstruction, and gastritis, nausea and vomiting, diffuse abdominal tenderness, distress, and sinus bradycardia with fusion complexes and had occasional cannabis use. 

There were no reports of clinical institute of withdrawal scale (CIWA) protocol or detoxification medications given, and the patient had abdominal pain with nausea and vomiting but she reportedly did not have unstable stable vital signs and there no reports of severe substance or alcohol withdrawal or the need for withdrawal detoxification treatment. There were no reports of acute psychiatric symptoms requiring inpatient hospital treatment as there were no reports of suicidal or homicidal ideation, intent or plan, hallucinations, delusional or disorganized thinking, aggressive or self-injurious behavior, substance or alcohol withdrawal symptoms that would have required inpatient hospital treatment then, manic or major depressive episodes, inability to adequately care for basic needs, or evidence that he was considered an imminent danger to self or others then.  She reportedly was being treated for abdominal pain with IV Morphine, Tylenol, Protonix, Toradol, Reglan, Zofran, and IV fluids. There were no reports of specific identifiable or quantifiable treatment objectives or goals that could only be achieved in a 24-hour inpatient medical, psychiatric, or detoxification hospital setting. 

It appeared that the health care plan acted reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.