Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overdose

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital treatment after a heroin overdose resulted in altered mental status. The patient reportedly also drank 2 gallons of liquor a few days prior to admission and had active alcohol withdrawal symptoms including a Clinical Institute Withdrawal Assessment (CIWA) of 8. The patient reportedly was sniffing heroin and cocaine daily and also using cannabis and ecstasy. The patient reportedly had a positive toxicology screen for cocaine and marijuana. The patient reportedly was given multiple doses of intravenous and nebulizer Naloxone and still had reports of altered mental status, dizziness and fatigue. The patient reportedly was put on a CIWA protocol with Ativan for detoxification. The patient reportedly was put on respiratory monitoring. The patient also reportedly had multiple medical problems including significant respiratory acidosis, hypercarbia, hyperglycemia, leukocytosis with left shift, and anemia. The patient reportedly also had depression and was diagnosed with Depressive Disorder, Polysubstance Dependence, and Alcohol Use Disorder. The patient reportedly was in past outpatient mental health treatment and had taken Zoloft and Buspirone. The patient reportedly had a past substance rehabilitation treatment. 

The medical records provided enough specific evidence to support that the patient required this level of care. The Milliman Care Guidelines (MCG) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. In this case this patient reportedly had a heroin overdose and required multiple Naloxone treatments intravenous (IV) and nebulizer and still had reports of altered mental status, so the patient required inpatient hospital treatment. The patient was at risk for another overdose as the patient reportedly was homeless and lacked supports. The patient also reportedly had alcohol withdrawal so the patient was at risk for more severe, complicated, and life threatening withdrawal such as delirium tremens. The patient also was at risk for other medical issues as the patient also reportedly was using cocaine and heroin daily as well as ecstasy and cannabis and was at risk for another overdose. Also, 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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. The patient was considered a high risk medically and in need of 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 an inpatient admission is substantiated.