Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Problems with Opioids
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is overturned.

The patient is an adult female. She presented to the emergency department. She was admitted for acute inpatient level of care to address substance use with prescribed opioids (prescription opiates) in the context of right hip replacement surgery and associated symptoms of pain. The patient has a co-occurring mood disorder with history of depression and multiple chronic medical conditions including hypertension, dyslipidemia, arthritis, lower back pain, diabetes mellitus and normocytic anemia, as well as the recent hip replacement surgery. She had run out of her opioid medication, oxycodone, and had withdrawal symptoms due to chronic use of these medications including vomiting, diarrhea, chills, and headache together with elevated blood pressure and fever and swelling at the incision site. The patient was admitted to inpatient hospital care with consultations from pain management, orthopedics, and addiction medicine. She was restarted on her pain regimen initially with Oxycontin and as needed use of oxycodone together with supportive measures including intravenous fluids and hydration and ongoing treatment of the chronic conditions. Other medications included amlodipine, Zofran, losartan, Cozaar, senna, MiraLAX, Ozempic, and memantine, as well as management of the diabetes. The patient gradually improved and was feeling better as she was rehydrated and had pain relief and resolution of the opioid withdrawal symptoms. The patient was discharged with continued use of oxycodone and follow up with orthopedics and pain management as well as her primary care physician. The health plan denied coverage of the inpatient admission based on medical necessity and MCG (Milliman Care Guidelines) Guidelines-Substance-Related Disorders indicating that there was no vomiting or diarrhea or dehydration warranting inpatient level care. The appeal was based on medical necessity and complex clinical judgment indicating that MCG (Milliman Care Guidelines) Guidelines pertaining to pain management and withdrawal management were met. The appeal referenced the comorbid conditions and presenting clinical features.

The inpatient admission was medically necessary for this patient.

The requested Inpatient admission and continued treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using prescription opioids and developed severe withdrawal symptoms and associated symptoms of pain after running out of opioid medications. Additionally, the patient presented with a history of a co-occurring depressive disorder and multiple general medical conditions complicating her clinical presentation. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, the 
scientific literature referenced below, and New York State instruction for medical necessity reviews including the appropriate application of the New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Tool required that the patient in this scenario default to the higher level of care. 
Therefore, the inpatient admission was medically necessary for this patient.