Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of asthma, schizophrenia, post-traumatic stress disorder, depression, and polysubstance use. He presented to the ED (emergency department) with altered mental status. The patient had been noncompliant with Methadone.

In the ED (emergency department), the patient was somnolent, but arousable. UDS (urine drug screen) was positive for benzodiazepine, cocaine and heroin. The patient was admitted with conditions including somnolence, drug Xanax overdose, and AKI (acute kidney injury).

Admission day 1, the patient's vital signs were as follows: temperature 36.8, pulse 74, respiration rate 20, blood pressure 136/74, and pulse oximetry 94%. The patient was arousable. His mental status was improving. He had right-sided facial droop and ptosis. CT (computed tomography) showed NAD (no active disease). He was prescribed one week of Amoxicillin for his dental pain. Psychiatry consult stated patient was stable and did not need psychiatric hospitalization.

Day 2,  the patient's vital signs were stable. He had normal affect. He complained of progressive abdominal pain. He was NPO (nothing by mouth). He was to continue IVF (intravenous fluids). The plan was for x-ray and CT (computed tomography). Methadone was to be titrated. He was medically cleared by psych for outpatient follow up.

Day 3, the patient's vital signs were stable. He complained of abdominal pain and constipation. He had no BM (bowel movement) for three days. Imaging was positive for constipation. His AKI (acute kidney injury) was resolving. His diet was resumed. His constipation was noted to be likely to have been opioid-induced. He was given tap water enema, Miralax and lactulose.

Day 4,  the patient's vital signs were stable. He complained of abdominal pain and constipation. He refused enema. He was to continue Miralax and lactulose. Abdominal x-ray revealed no active disease.

Day 5,  the patient's vital signs were stable. He complained of nausea and constipation. He had BM (bowel movement) with blood. His abdominal distention was noted to be better. He was to continue Miralax, Senna and solace.

Day 6, the patient's vital signs were stable. He complained of nausea and vomiting. Had BM (bowel movement) the prior night. He was to start PPI (proton pump inhibitor), attempt Golytely for constipation, and consider GI (gastroenterology) consult.

Day 7, the patient's vital signs were stable. He complained of abdominal pain and constipation. He was given Golytely with minimal response.

GI (gastroenterology) consult was performed for constipation. The patient was given tap water enema, Golytely, Miralax, Senna, colace and IV (intravenous) Metoclorpromide.

Day 8,  the patient's vital signs were stable. He still had no BM (bowel movement). CT (computed tomography) revealed no ileum or SBO (small bowel obstruction). He had opiate-induced constipation. He was to consider methyl-naltrexone.

Day 9,  the patient's vital signs were stable. He was to continue bowel regimen and another 2L (two liters) of Golytely.

Day 10, the patient's vital signs were stable. He was to continue bowel regimen and hydration. He was discharged with Movantiq.

No, the Inpatient admission was not medically necessary.

Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice.

This patient with multiple conditions, including opioid use disorder, was admitted with altered mental status after benzodiazepine overdose and Methadone noncompliance. His mental status was improving. The patient was hemodynamically stable. There is no documentation of arrhythmia. The patient did not have seizures. Methadone was resumed. Psychiatry did not recommend inpatient psychiatry admission. The patient had not failed an observation level of care for monitoring of benzodiazepine withdrawal. During hospital stay, the patient complained of abdominal pain with constipation, which was determined to likely be opioid-induced constipation. The remainder of the hospital stay is remarkable for work up and treatment of constipation. The patient remained hemodynamically stable and was tolerating PO (by mouth). He did not have significant electrolyte abnormalities. The intervention for constipation did not require an acute in patient level of care.