Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay.  The denial is upheld.

The patient is a female with a past medical history significant for polysubstance abuse and psychotic disorder, who was brought to the emergency department by Emergency Medical Services (EMS) after she overdosed on Oxycodone, Trazodone, Klonopin, and Seroquel on the anniversary of her fiance's overdose death.  The patient's father called Emergency Medical Services (EMS), and the patient was transported to the emergency department.  Upon initial presentation, she was slightly sedated but subsequently started waking up more and more.  The patient stated that she was under a lot of stress.  Upon initial evaluation in the emergency department, the patient was found to have a long QTc interval on the electrocardiogram (EKG).

At that time the patient's temperature was 98.8F, pulse rate was initially in the 80's. The blood pressure was 134/88, respiratory rate was 16 breaths/minute (min).  The patient was a non-ill-appearing female who was awake and alert.  She answered questions reluctantly.  The patient followed simple commands.  Her pupils were round. The admitting physician raised concern for possible depression and suicidal ideation versus attempt.  The urine drug screen was positive for Methadone, Fentanyl, Oxycodone, benzodiazepines, and tetrahydrocannabinol (THC).

The patient was admitted to the hospital with multiple drug overdoses, polysubstance abuse, depression, tobacco dependency, elevated AST and ALT, and possible suicide attempt. During the hospital stay, the patient underwent a computed tomography (CT) scan of the head and a CT scan of the cervical spine. These studies were unremarkable. Throughout the hospitalization, the patient became agitated and received treatment with intravenous Haldol and Ativan.  Subsequently, her agitation resolved. Since the patient remained in stable clinical condition, she was transitioned to the inpatient psychiatric unit.

At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.

This patient remained in a stable clinical condition.  There were no signs of hemodynamic instability.  The prolonged QTc interval resolved.  The elevation of AST was minimal and had no clinical significance.  This patient did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.  Even though the patient presented to the hospital with overdosing multiple medications, there were no signs of severe withdrawal. Her heart rate did not sustain over 100 beats per minute (bpm) continuously.  On the next day after the day of admission, the patient was awake, alert, and oriented times three. She was drowsy but responsive.  Cranial nerves were intact, and the patient was able to move all four extremities.  There was no focal weakness. There was no anxiety or agitation documented.  On the next day, her heart rate continued to be in the range between 88 and 110 bpm. The blood pressure remained within a normal range. The neurologic exam remained grossly nonfocal. There were no reports of anxiety. 

There was no mention that this patient had persistent nausea or vomiting, tremors, increased perspiration, or any other signs of withdrawal. There was no evidence that the patient had seizures related to withdrawal from medications. There was no evidence that the patient had acute toxicity or instability from substance use such as hallucinations. There was no mention that this patient definitively expressed suicidal ideation or imposed imminent danger to herself.   Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.

Therefore, the Inpatient Stay was not medically necessary.