Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital due to a syncopal episode in which he lost consciousness for approximately 5 minutes and fell resulting in an occipital headache. It was reported that he was using cocaine which likely resulted in tachycardia and an arrhythmia and the syncopal episode. Interrogation of his ICD (implantable cardioverter defibrillator) showed a shock for VT/VF (ventricular tachycardia/ventricular fibrillation) was responsible for the syncope. He reportedly was regularly using cocaine and alcohol. He reportedly had a serious medical history for CHF (congestive heart failure), hypertension, atrial fibrillation, and kidney problems, and had severely low ejection fraction, mild pulmonary vascular congestion, moderate mitral regurgitation, and diastolic dysfunction with increased LA (left atrial) pressure. He reportedly was on telemetry and had medication changes including having Lasix switched to Toresemide, and Toprol and Entresto were started. He reportedly was discharged when considered medically stable.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that he was not medically unstable, and they recommended a less restrictive level of care.
The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment from he was discharged as the medical records provided enough specific evidence to support that he was considered a medical risk and in need of medical hospital treatment then. 
It was reported that cocaine use was likely responsible for the cardiac issues of syncope related to VT/VF treated by the ICD, headache due to a fall from the syncope, and he had a low baseline functioning ejection fraction and other cardiac issues including CHF, hypertension, atrial fibrillation. He was not considered safe for treatment outside of a medical hospital then and his symptoms appeared related to cocaine use. The MCG (Milliman Care Guidelines) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. In this case this patient had cocaine use contributing to cardiac issues putting him at risk medically. He reportedly was using cocaine and alcohol regularly and the cocaine use resulted in shock from his automatic defibrillator and feelings of electric current through his entire body which resulted in a syncopal episode, fall and headache, loss of consciousness, tachycardia and arrhythmia, and he had a low baseline cardiac status with severely low ejection fraction, mild pulmonary vascular congestion, moderate mitral regurgitation, and diastolic dysfunction with increased LA pressure. He had medication changes, consults, and was on telemetry, and was not considered medically stable until discharge. He was considered a high risk for more cardiac problems due to cocaine use. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the insurer acted reasonably, with good clinical judgment, or in the best interests of the patient then.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.