Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a female who presented to the Emergency Department (ED) on via Emergency Medical Services (EMS) in a cervical collar.  EMS gave 2 milligram (mg) Narcan intranasally with minimal response.  She was reportedly found face down on the street after possibly using heroin and was found in a pool of her blood, unresponsive and having agonal respirations.  Her Glasgow Coma Scale (GCS) score was 9.  She was given Narcan 1 mg (milligram) intranasally in the Emergency Room (ER) and became more responsive.  Her diagnoses listed anxiety, depression, drug abuse, ethanol alcohol (ETOH) abuse and seizures related to alcohol abuse.  Her vital signs were blood pressure (BP) 109/75, heart rate (HR) 102, Temperature 97.7F, respiratory rate (RR) 30 and oxygen saturation (SpO2) 93%.  Her exam noted that she was awake and alert, no active bleeding, good respirations, no neurological deficits. The Review of Systems (ROS) noted unable to perform ROS, mental status change, agitation, behavioral problems and decreased concentration.  Another exam noted bilateral pupils pinpoint and minimally reactive and motor weakness.  The plan was for trauma/toxicology labs, chest x-ray, computed tomography (CT) head and cervical spine, CT chest/abdomen/pelvis, continuous pulse oximetry, electrocardiogram (EKG) and place on monitor.  Consult to Trauma Surgery and Neurosurgery.  A CT of the cervical spine showed a C6 (sixth cervical bone) avulsion fracture on spinous process.  CT of brain history noted head trauma, moderate to severe, GCS<13 initial exam and noted minimal right frontal scalp swelling, otherwise unremarkable.  She was given IV calcium, D50 (dextrose 50%) and 5 units of insulin for hyperkalemia.  She was admitted for magnetic resonance imaging (MRI), IV fluids, observe for alcohol withdraw and maintain cervical collar per Neurosurgery recommendation and repeat labs in am.  She was placed on Clinical Institute Withdrawal Assessment of Alcohol (CIWA) protocol.  She then received IV bolus of lactated ringers 1000 ml (millileter), was ordered strict bedrest and nothing by mouth.  IV Pepcid, oral Librium, and lab work were ordered.  Her IV fluids of normal saline were infusing at 125 cc/hr (cubic centimeter per hour).  MRI of the cervical spine completed and noted minimal cervical degenerative changes at C4-5 (fourth and fifth cerical bones) and C5-6 (fifth and sixth cervical bones).  

Per Milliman Care Guidelines (MCG) Drug Ingestion or Overdose, hemodynamic instability with hyperkalemia correction and lactic acidosis greater than 2 mmol/L (millimole per liter), hypotension, significant finding or clinical condition judged too severe for altered mental status, ongoing telemetry monitoring, ongoing inpatient for ongoing antidote treatment for CIWA protocol every four hours for ETOH initially critical at 380 and ongoing monitoring with medications available.  InterQual Guidelines as they stated for Intermediate Cardiac/telemetry inpatient for toxic level of drugs/chemicals and potential for significant arrhythmia with hyperkalemia; InterQual Guidelines, General Medical inpatient for neurologic assessment every three to four hours and CT or MRI performed or scheduled within 24 hours for acute onset of a neurological impairment or condition; Potassium greater than 5 with severe weakness and severe medical etiology of drug overdose.  MCG Hemodynamic Instability: Common Complications and Conditions for ongoing inpatient care for lactic acidosis 2 mmol/L and new altered mental status.  The patient needed critical treatment and ongoing monitoring of her neurological status, imaging, IV fluids to maintain blood pressure, CIWA monitoring and care could not have been provided at a lower level of care.  She was discharged when hemodynamically stable for no further hypotension evidenced by rising blood pressures and her neurological status returned to baseline. 

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 admission is reversed. Medical necessity is substantiated.