Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health-Other-Drug overdose
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for anxiety, depression, hyperlipidemia, bipolar disorder, migraines, human immunodeficiency virus (HIV), lymphoma, and previous suicide attempts who came to the emergency department due to intentional drug overdose.
One day before the day of her presentation the patient was unable to sleep, therefore, she took 4 pills of Depakote, 500 milligrams (mg) each, then another 4 pills of Depakote, 6 pills of Gabapentin, 300 mg, as well as 3 pills of Sertraline 100 mg and two pills of Seroquel 400 mg, also a handful of Excedrin pills. When seen by the emergency department physician, the patient stated that she did not try to commit suicide and took pills only because she was unable to sleep. At the same time, it was reported that before the presentation to the hospital, the patient contacted her psychiatrist and mentioned a suicide attempt.
When seen in the emergency department, the patient complained of dizziness and lightheadedness. The review of systems was also positive for vomiting, but the rest was negative. 
Upon initial evaluation in the emergency department, the patient was admitted to the telemetry unit, and poison control was contacted. They recommended serial electrocardiograms (EKGs) and checking valproic acid levels. In the hospital, the patient was seen by a psychiatrist who confirmed the diagnosis of schizoaffective disorder. The psychiatrist recommended involuntary observation with subsequent transition to inpatient psychiatric facility for stabilization. During the hospital stay, the patient remained afebrile and hemodynamically stable. Therefore, the patient was transferred to an inpatient psychiatric facility.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital after a drug overdose, however at the time of the presentation she denied suicidal ideations. She had no intent or plan in place to commit suicide. At the time of the initial evaluation and during the hospital stay, this patient remained hemodynamically stable and had no significant abnormalities in the laboratory studies and did not require any treatment necessitating admission at the acute inpatient level of care. The patient was seen by a psychiatrist who documented in the consultation note that the patient told him that she did not want to commit suicide. Considering the fact that the patient took multiple medications in high doses, the admission at a lower level of care was definitely indicated to watch for signs of toxicity including cardiac arrhythmias, electrolyte abnormalities. Since the patient remained in a stable clinical condition, she was transitioned to an inpatient psychiatric facility the next day after the day of admission.
Taking into consideration all these facts, the admission at a lower level of care seems to be the most appropriate to ensure medical stability in the setting of a drug overdose before transitioning the patient to psychiatric care.