Appeal type: Medical necessity
Decision: Overturned in Part

Substance Abuse/Addiction
Inpatient Hospital

This is the case of a male with past medical history (PMHx) of polysubstance use and suicide attempts who presented to the emergency room (ER)  after he was found unresponsive, covered in vomit, and with a needle next to him. He received Zofran and did not require Narcan en route to the hospital.
On presentation, he was noted to be afebrile with blood pressure (BP) 108/71, heart rate (HR) 80, respiratory rate (RR) 18, and sating 98% on room air (RA). Exam otherwise noted the patient to be drowsy, confused, and to have constricted pupils. Labs showed white blood cell (WBC)count 9.1, hemoglobin (HGB) 15.3, platelets (Plts) 168, sodium (NA) 142, potassium (K) 4.1, blood urea nitrogen (BUN) 25, creatinine 1.1, lipase normal, and ethanol (EtOH) level undetectable, Tylenol and salicylate levels undetectable, and liver function tests (LFTs) grossly normal. Urine drug screen (UDS) was positive for opiates, cocaine and benzos. Electrocardiogram (EKG) noted normal sinus rhythm (NSR) without acute ischemia or arrhythmia. Computed tomography (CT) head showed no acute process. chest x-ray (CXR) showed no acute process. The patient was subsequently brought into the hospital with assessment that he had overdosed and plans for Narcan as needed (prn), psych consult, telemetry monitoring, and 1:1 sitter.
He was seen by psychiatry with assessment that he was high risk for suicidal behavior and required ongoing 1:1 sitter with recommendations for inpatient psychiatric hospitalization. He was seen by addiction medicine with recommendation for psychiatry consultation.
The patient was noted to be hemodynamically stable and to be ambulating in the hallway. He was otherwise not cooperative and would not engage in conversations regarding his drug abuse. He denied suicidal ideation (SI). The plan was to initiate venlafaxine and transfer to a psychiatry bed once available and to continue constant observation.
The patient continued to deny suicidal ideation. He reported he needed to leave to make money and wanted to be discharged. He was ultimately discharged home to the care of his parents.
The issue in question is whether treatment at the acute inpatient level of care was medically necessary.

The health plan's determination is overturned, in part. 

In part. The patient required inpatient care for a portion of the dates given he was unsafe to discharge and remained on a 1:1 sitter.
This is a patient with a history of polysubstance use who presented to the ED after being found down covered in vomit. It is noted that he never required Narcan per notes and arrived lethargic but otherwise hemodynamically stable. Labs did not reveal any acute medical abnormality requiring treatment and he did not have imaging evidence on CT head of acute abnormality or of aspiration on CXR. Given his presentation, that he had overdosed on multiple substances, and the concern that he was suicidal, he was certainly appropriate to bring in for monitoring. It is notable, however, that he remained hemodynamically stable  without signs of withdrawal or other acute medical process. He was deemed unsafe to discharge continuing to require 1:1 sitter and the primary plan of care was awaiting a psychiatric bed in addition to initiation of venlafaxine and 1:1. He continued to be seen by psychiatry and was ultimately deemed stable from a psychiatric perspective to discharge to home with his parents.