Appeal type: Medical necessity
Decision: Upheld

Diagnosis: multi-substance abuse.
Treatment: Inpatient Emergency Admission.
The insurer denied: Inpatient Emergency Admission.
The denial is: Upheld

The patient is a male with a past medical history significant for hypertension, alcoholism, and multi-substance abuse who was initially admitted to a rehabilitation facility for detox. He was referred to the hospital for evaluation of elevated blood pressure. The patient stated that the medications that were given to him did not help with withdrawing from heroin.
The review of systems was positive for body aches, abdominal pain, runny nose, and nausea.
The patient denied fever, lightheadedness, numbness, tingling, blurriness, sore throat, chest pain, palpitations, cough, shortness of breath, diarrhea, constipation, or any other symptoms.
Upon initial evaluation in the emergency department, the patient had a blood pressure of 172/120 with a pulse rate of 110.
He received treatment with labetalol, intravenous fluids, hydralazine, Zofran, methylnaltrexone, and sucralfate.
Computed tomography (CT) scan of the head was negative for acute intracranial pathology.
CT scan of the abdomen and pelvis revealed a prominent caliber of the central bile duct and intrahepatic bile duct. The extrahepatic common bile duct measured up to 1 centimeter (cm) with no visible stones.
During the hospital stay, the patient sustained a fall going to the bathroom. At that time, he was hypotensive. Due to hypertension, his antihypertensive medications were discontinued with subsequent improvement in blood pressure levels.
During the hospital stay, the patient completed his detoxification from ethanol and opioids by successfully tapering off methadone and Ativan. He was cleared for discharge home with outpatient follow-up.
The subject under review is the medical necessity for the inpatient emergency admission.

The health plan's determination is upheld.

The inpatient emergency admission was not medically necessary for this patient. Based on the nationally accepted standards of care, admission at the acute inpatient level of care is recommended for patients who demonstrate symptoms and signs of withdrawal from alcohol, sedatives, and opioids with high-risk indicators including sustained heart rate greater than a hundred bpm, persistent nausea and vomiting, tremor, increased perspiration in conjunction with a history of delirium, history of repeated seizures, intrinsic seizure disorder.
Admission for withdrawal from opioids is usually indicated for patients with vomiting or diarrhea in conjunction with severe dehydration and electrolyte abnormalities that could not be managed in the emergency department or in the observation settings.
The hypertensive urgency that the patient experienced at the time of admission was likely triggered by alcohol and opioid withdrawal, but the blood pressure went down quickly to the point that the patient was taken off antihypertensive medications.
Taking into consideration all these facts, the admission for monitoring was most appropriate to ensure the resolution of the mild withdrawal symptoms, as well as for checking blood pressure and adjustment of antihypertensive medications.
Even though the patient reported a previous history of syphilis, he did not need any treatment in the hospital that would justify the acute inpatient level.