Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cocaine Use Disorder.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This patient was admitted to inpatient hospital due to pneumomediastinum and pneumonia as he had a reported exacerbation of asthma including cough with productive sputum, shortness of breath, wheezing, chest pain, and elevated heart rate of 155. It was reported that cannabis and cocaine use contributed to this. It was reported that he last used these substances one day prior to admission. It was reported that his D-dimer and lactate level were elevated. The patient reportedly had a positive toxicology for cannabinoids and cocaine. He reportedly was given antibiotics, steroids, and breathing treatments. He reportedly was put on 1:1 observation for safety and elopement concerns. He reportedly was seen by a psychiatric consultant and was given a diagnosis of adjustment disorder and Cocaine Use Disorder. It was reported that the patient did not demonstrate the decisional capacity to leave AMA (against medical advice). The psychiatric consultant determined that the patient did have the decisional capacity to leave AMA and he was discharged.
  
This patient had reports of medical issues related to cocaine and cannabis use including pneumomediastinum and pneumonia as he had a reported exacerbation of asthma including cough with productive sputum, shortness of breath, wheezing, chest pain, and elevated heart rate of 155, as well as elevated lactate and D-dimer which required treatment with antibiotics, steroids, and breathing treatments. The MCG (Milliman Care Guidelines) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. In this case it was reported that this patient had medical issues requiring treatment which likely were due to cocaine and cannabis use including pneumomediastinum and pneumonia as he had a reported exacerbation of asthma including cough with productive sputum, shortness of breath, wheezing, chest pain, and elevated heart rate of 155, as well as elevated lactate and d-dimer which required treatment with antibiotics, steroids, and breathing treatments. The psychiatric consultant reported on that the patient did not demonstrate the decisional capacity to leave AMA, so the patient did not at that time have the ability to care for his basic needs and was not willing to participate voluntarily in his necessary medical care and treatment including steroid, antibiotic, and breathing treatments. His medical symptoms reportedly were likely to worsen putting him at risk medically for more severe medical issues and conditions. The patient reportedly was using cocaine and cannabis which reportedly contributed to his medical conditions. If he left at that time he likely would have not followed up with his medical and substance use issues. However, it was reported by the psychiatric consultant that the patient improved in his ability to make decisions and demonstrated decisional capacity to leave AMA. It was reported that he was able to verbalize his current active medical issues of pneumomediastimum and risks of foregoing his current treatment. It was reported that he denied suicidal or homicidal ideation, had no evidence of current psychotic symptoms, had goal directed thought process, was calm, had normal speech, intact insight and judgment. It was reported that he was future oriented and hopeful. It was reported that he was living with a supportive girlfriend, did not meet criteria for psychiatric hospitalization, and was agreeable to engage in Rehab for substance use. 1;1 observation was discontinued, and he also was referred for outpatient mental health treatment. It was reported then that there was no contraindication to be being discharged. This was a change on admission when it was reported that he did not have decisional capacity to leave AMA or the understanding of the risks of foregoing medical treatment then and also did not agree to substance and mental health follow up 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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.