Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug overdose

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This adult patient was admitted to this hospital due to altered mental status and respiratory depression as she had a decreased respiratory rate and carbon dioxide (CO2) over 44. She was lethargic and thought to have an overdose of fentanyl and cocaine as she reportedly had taken these. She had a positive toxicology screen for cocaine and cannabis. She was admitted to the intensive care unit (ICU) due to mental status changes and respiratory depression and was put on a Naloxone continuous drip, close monitoring of respiratory status and mental status, had a psychiatric and critical care consultation, and had serial neurological and respiratory assessments. The patient stabilized and was discharged.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that she did not require 24-hour inpatient hospital treatment and that she could have been treated in a less restrictive level of care.

The medical records provided enough specific evidence to support that she required this level of care. The Milliman Care Guidelines (MCG) Drug Ingestion/Overdose criteria states that one of the following needs to be met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission as required other than observation care. 

In this case this patient had an overdose of two serious substances including fentanyl and cocaine which put her at high medical risk for overdose and respiratory depression as well as other medical issues. She reportedly had respiratory depression and altered mental status with lethargy and high CO2 (carbon dioxide) which put her at high risk medically and for death from overdose and respiratory depression. She required and received acute medical treatment including Naloxone continuous drip, close monitoring of respiratory status and mental status, had a psychiatric and critical care consultation, and had serial neurological and respiratory assessments. She was in the ICU. She reportedly was using fentanyl and cocaine and the concern was for drug overdose. She could not safely and effectively be managed and treated in a less restrictive setting other than this acute hospital setting. The patient required acute hospital inpatient admission and not just observation care. She was considered at high risk for overdose and death from respiratory depression and required the very close monitoring and treatment in the hospital setting in the ICU. Once her mental status and respiratory status improved due to the intensive treatment in this acute hospital setting, she was discharged. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.