Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Detox and Skin Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male with a history of polysubstance abuse. He presented to the ED (emergency department) requesting detox. He last used heroin the day before. He complained of irritability, anxiety, chills, nausea, joint pains and abdominal cramps.

The patient's vital signs were as follows: Temperature 98.2, pulse 78, respiration rate 18. His exam was remarkable for bumps at injection site with warmth, redness and tenderness. The patient's labs were as follows: WBC (white blood count) 10.68, H/H (hemoglobin/hematocrit) 13.5/41.8, Plt (platelets) 346, Na (sodium) 128, K (potassium) 4.0, BUN/Cr (blood urea nitrogen/creatinine) 21/1, VBG (venous blood gas) 7.4/59/34/35, and Lactate 1.2. Urine toxicology was positive for benzodiazepines and opiates. Chest x-ray revealed no active disease. EKG (electrocardiogram) revealed NSR (normal sinus rhythm) and QTc (corrected QT interval) 422. His COWS (clinical opiate withdrawal scale) score was 7. His CIWA (clinical institute withdrawal assessment) score was 4.

The patient was admitted. Plan of care included Lorazepam, methadone protocol, IVF (intravenous fluids), and IV (intravenous) antibiotics for arm cellulitis.

On day two, the patient's vital signs were stable. Vomiting was reported. The plan was to continue current management.

On day three, the patient's vital signs were stable. He denied symptoms of withdrawal. His COWS (clinical opiate withdrawal scale) score was 0. His CIWA (clinical institute withdrawal assessment) score was 0. The plan was to continue current management.

On day four, the patient's vital signs were stable. His Na (sodium) was 136. He signed out AMA (against medical advice).

No, the Inpatient admission was not medically necessary.
This patient with a history of polysubstance use was admitted for opiate and benzodiazepine withdrawal. The patient was hemodynamically stable and afebrile. He did not have tachycardia, arrhythmia, or prolonged QTc (corrected QT interval). He complained of nausea. He did not have vomiting, tremor, or perspiration. There were no physical signs of withdrawal. Labs were remarkable for hyponatremia positive urine toxicology. His COWS (clinical opiate withdrawal scale) score was 7. His CIWA (clinical institute withdrawal assessment) score was 4. He was found to have upper extremity cellulitis. He did not have bacteremia. He did not have a limb threatening infection. The patient was admitted with planned COWS (clinical opiate withdrawal scale) and CIWA (clinical institute withdrawal assessment) protocols and management with lorazepam and methadone as well as IV (intravenous) antibiotics for cellulitis.

The patient's hyponatremia corrected during his hospital stay. He remained hemodynamically stable and afebrile, and with no signs of severe withdrawal. The patient signed out AMA (against medical advice). He did not have symptoms that required an acute inpatient level of care. He had not failed management in a lesser level of care.

Therefore, given the above, inpatient admission was not medically necessary.

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