Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug Overdose
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a male with a past medical history significant for obstructive sleep apnea, status post-tonsillectomy, uvulectomy, multiple sinus procedures, Wolff-Parkinson-White (WPW) syndrome with ablation, lumbar stenosis, depression, and anxiety. He presented to the hospital with altered mental status after he ingested 6 marijuana edibles. The patient denied falls, head injuries, fever, chest pain, palpitations, and abdominal pain. The patient stated that he did not drink alcohol and he did not use tobacco products or other recreational drugs.
Upon the initial evaluation in the emergency department, the patient was afebrile. His pulse rate was 115 beats per minute (bpm), blood pressure 149/94, respiratory rate 20 breaths per minute, and his oxygen saturation was 95 percent (%) on room air.
The patient appeared to be a middle-aged male who was drowsy. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. His lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The patient's abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. His extremities were warm and well-perfused with no edema or clubbing. The patient was awake, alert, and oriented times 3 with no focal sensory-motor deficits. His gait was normal and his pupils were equal and reactive to light.
The laboratory evaluation revealed that his sodium was 138, potassium 4.4, chloride 106, bicarbonate 24, blood urea nitrogen (BUN) 19, creatinine 0.88, and his glucose was 114. His sodium was 8.8, hemoglobin 15.9, hematocrit 45.8, platelets 111 and his calcium was 9.1. The computed tomography (CT) scan of the head did not show acute abnormalities. A chest x-ray did not show any evidence of acute disease. The urine toxicity screen came back positive for cannabis.

The patient was admitted to the hospital and was monitored overnight without any issues. The patient remained afebrile and hemodynamically stable. At the time of discharge, he was awake, alert, and oriented times 3 with no focal sensory-motor deficits. 

The requested health service/treatment of full hospital admission is not medically necessary. Based on the information provided in the previous report, admission at an alternate level of care was the most appropriate for this patient with a cannabis overdose. The patient did not exhibit any alarming signs or symptoms that would require admission to an acute inpatient level of care. Cannabis overdose is typically managed with supportive care and monitoring, which can be provided in an alternate level of care or emergency department. The patient did not have any underlying medical conditions or severe psychiatric symptoms that would require hospitalization. However, in rare cases, cannabis overdose can cause significant medical problems that require hospitalization. 

Indications for admission at an acute inpatient level of care for patients with cannabis overdose may include severe respiratory depression, which can lead to respiratory failure, hypotension, or hypovolemia due to vomiting or diarrhea, and severe psychiatric symptoms such as psychosis or suicidal ideation. Patients with underlying medical conditions that are exacerbated by cannabis use may also require hospitalization for the management of these conditions. 

In this clinical case, the patient was in stable clinical condition and had no alarming signs that required further intervention or procedure justifying admission at the acute inpatient level of care. Therefore, an alternate level of care seems to be the most appropriate, given the clinical circumstances. 

The health plan's determination of medical necessity is upheld in whole.