Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lower extremity ulcers.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  The denial is reversed. 

This was then a female patient who was admitted to the hospital with multiple lower extremity ulcers that were oozing purulent drainage.  The patient was noted for lower extremity swelling, blisters, abscess, and hypovolemic hyponatremia (sodium level of 131), acute kidney injury (creatinine level of 1.17), agitation, uncooperativeness.  The patient was at risk of severe withdrawal, as it was reported that she was injecting heroin daily into her lower extremities.  During inpatient stay, the patient was monitored for withdrawal and was treated with multiple intravenous (IV) antibiotics, IV fluids, and insulin.  The patient had a reported medical history significant for diabetes and a chronic liver disease with hepatic coma.  The patient was homeless and reported that she had not been taking her diabetes medication.  The patient reportedly left the hospital against medical advice (AMA).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

In this case, this patient had serious medical problems including multiple abscesses in her lower extremities due to injecting heroin daily into them and required multiple intravenous antibiotic administrations for treatment.  The patient was non-compliant with her diabetic medications and was found to have hypovolemic hyponatremia (sodium level of 131) and acute kidney injury (creatinine of 1.17) that required glucose treatment with insulin and intravenous fluid hydration, respectively. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24-hour treatment, as she could not safely and effectively be treated at outpatient settings and continued to use daily IV heroin resulting in serious medical issues and consequences.  The patient had multiple comorbid medical conditions complicating the monitoring of withdrawal and she required inpatient hospital treatment, as she was at risk for severe withdrawal or overdose due to her daily IV heroin use.  The patient was noted to be agitated, lacked supports and the coping skills to stop heroin use.  The patient also had an acute infection with comorbid diabetes not compliant to outpatient treatment.  Considering this patient's homelessness and uncontrolled diabetes (blood glucose of 293 on admission), this patient was at high risk for sepsis or other medical complications if not treated appropriately in an inpatient setting.  As a result, the inpatient medical hospital treatment was medically necessary to treat this patient's medical condition.

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be reversed.