Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status (suspected drug overdose)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient was brought to the emergency department by ambulance after he "stumbled" into a store and went down. He presented with altered mental status in a state of mental confusion. On initial evaluation his blood alcohol level was 13 with low phosphorus, magnesium and elevated ammonia at 128 reflecting a metabolic abnormality and findings consistent with a toxic and/or metabolic encephalopathy. Additional testing revealed elevated CK (creatine kinase) at 480; he displayed sinus rhythm on EKG (electrocardiogram). A CT (computed tomography) scan of the head and a Chest X-Ray were obtained with no evidence for head trauma or pneumonia. He received fluid and electrolyte replacement and other supportive measures with admission to acute inpatient level care after eight hours of observation and treatment in the emergency department with two doses of Ketamine and one dose of Haldol for agitation, as well as receiving Narcan without improvement. Recommendations were for cardiac monitoring, safety monitoring and neurology consultation.

The patient received vitamin replacement therapy with continued fluid and electrolyte replacement and monitoring. He was monitored with seizure and fall precautions, as well as receiving cardiac monitoring and support from staff and one to one observation. Neurology consultation with MRI (magnetic resonance imaging) and EEG (electroencephalogram) concluded that the patient was likely delirious due to alcohol or a drug overdose despite a negative drug screen (presumptive and confirmatory).

On his second day of treatment, the patient's mental status improved with a resolving delirium. He was alert, oriented and in no further distress. Speech was clear with linear and logical thought processing. He had no severe symptoms such as mania, depression, perceptual disturbance or severe cognitive impairment, and denied suicidal ideation or aggressive impulses. Insight was fair and judgment intact. Vitamins were continued, as well as comfort medications with monitoring and assistance with daily activities. He was maintained on fall and seizure precautions. His demeanor improved and he was discharged with plans for clinically appropriate aftercare.

Yes, the proposed treatment is "medically necessary" for this patient.
The proposed inpatient could not have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's presumptive disorder and medical complications did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the disturbance and objective findings, and the presentation with several co-morbid medical complications consistent with encephalopathy and a presumed drug overdose. The patient was managed with supportive measures and monitoring while undergoing additional evaluation for an underlying cause of the altered mental status, as well as comfort medications and vitamin replacement therapy. It was not reasonable that the patient would have been safe to receive treatment at a lower level of care, as the health plan asserts. This answer is consistent with the ASAM (American Society of Addiction Medicine) Criteria and with New York State instruction concerning medical necessity reviews including the application of NY (New York) State OASAS (Office of Addition Services and Support) LOCADTR 3.0 (New York State Level of Care for Alcohol and Drug Treatment Referral 3.0) Criteria and Guidelines that indicated the necessity and appropriateness of the inpatient level treatment in this case.

The patient in this case presented with altered mental status in the context of a presumed drug overdose and findings consistent with encephalopathy and delirium. The patient presented with general medical complications, as noted in the clinical summary with the need for ongoing monitoring and evaluation for an underlying cause of the altered mental status.

The presenting clinical features and history and risk for withdrawal seizures and continued general medical complications did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay could not have been safely or effectively provided at a lower level of care in this case scenario, as noted in the answer to question 2 and as asserted in the appeal.