Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug intoxication
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patent is a male with medical history significant for polysubstance use (alprazolam, CBD [cannabidiol], LSD [lysergic acid diethylamide], mushrooms, marijuana, Kratom), anxiety, self-mutilation, and prior suicide attempts. He was taken to the ED (emergency department) via EMS (emergency medical services) after his parents found him screaming and talking nonsense. He was aggressive with family members. There were no reported seizures, no vomiting, no weakness. This was his third trip to the ED with drug intoxication.

The patient's vital signs included temperature 98, heart rate 124, respiratory rate 18, and blood pressure 91/57. His examination was significant for non-toxic appearance, not diaphoretic, no acute distress, dry mucous membranes, pupils 5 mm (millimeters) and reactive, healed scars on both forearms, anxious mood, angry and inappropriate affect, uncooperative and aggressive behavior, and inappropriate judgment. Laboratory evaluation was significant for mild hyperglycemia (glucose 117), creatine kinase 85, unremarkable alcohol and acetaminophen and salicylate levels, normal troponin, urine toxicology positive only for cannabinoid, moderate blood on urinalysis, unremarkable coagulation studies, and unremarkable metabolic panel. Poison Control was contacted with recommendations for symptomatic treatment.

The patient was admitted to the pediatric floor for further care of substance intoxication. Admission orders included 1:1 monitoring, Psychiatry consultation, Adolescent consultation, Social Services involvement, regular diet, and vital signs every four hours.

Upon admission, the patient was found to be bradycardic, prompting an electrocardiogram. Cardiology was consulted, noting benign sinus bradycardia. Psychiatry was consulted, with recommendations to treat symptomatically including Zyprexa as needed for agitation/aggression, Ativan as needed for agitation/withdrawal, and Zoloft daily for depression. They followed the patient for the duration of his hospital stay. He was given psychiatric clearance. Poison Control was contacted and was cleared for discharge from cardiac monitoring. Adolescent Medicine was also consulted and followed the patient for the duration of his hospital stay. He was medically cleared for discharge to follow-up with Adolescent Medicine, Psychiatry, and Cardiology.

Yes, the Inpatient admission was medically necessary.

Cannabis is a commonly used psychoactive substance that occurs naturally as a plant and interacts with the endocannabinoid system in the central nervous system. Tetrahydrocannabinol is the main psychoactive component and along with cannabidiol are the two most common cannabinoids. Long-term use may cause distorted perception, poor concentration, psychosis, excessive vomiting, and additional symptoms. In adolescents, impairment of neurocognitive functioning may occur. Toxicity is also possible with ingestion of high concentrations of cannabinoids and may result in sedation, respiratory depression, hyperemesis, and cardiotoxicity. Unintentional ingestion in children may result in lethargy, ataxia, mydriasis, hypotonia, and tachycardia.

This young man with longstanding history of anxiety, depression, self-mutilation behaviors, attempted suicide, and drug use and abuse was taken to the ED because of erratic behaviors and concern for illicit drug ingestion and intoxication. He was admitted per Poison Control for monitoring and symptomatic treatment. Psychiatry, Social Services, and Adolescent Medicine were all consulted to participate in his management. He was found to have persistent bradycardia, prompting additional consultation by Cardiology. After comprehensive evaluation by all subspecialists while monitoring his clinical condition, he was deemed stable for discharge, cleared medically and psychiatrically. The level of care that this adolescent patient received during his hospital stay was most consistent with acute inpatient care, including close monitoring and evaluation for both medical and psychological etiologies for his presenting and ongoing symptoms. Lower level of care would not have been appropriate in this case.