Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug overdose.
Treatment: inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is overturned. 

This female patient has a history of anxiety and major depressive disorder.  She presented to the Emergency Room (ER) after taking 24 pills of Lexapro-10 milligrams (mg) each and 8 pills of Ambien- 5 mg each.  Heart rate was 120 beats per minute.  An electrocardiogram (EKG) revealed sinus tachycardia.  White blood cell count was 10.2, hemoglobin was 14.8, hematocrit was 43.2, platelet count was 236, and neutrophils were 84.9%.  Basic metabolic panel was within normal limits (WNL).  A urinalysis revealed s specific gravity of 1.018, trace leukocyte esterase, negative ketones, blood, and nitrites.  Acetaminophen level and acetylsalicylic acid level were WNL.  Poison control was contacted.  They recommended observing the patient for 24 hours post-ingestion for seizures, altered mental status, serotonin syndrome, and hypoglycemia.  The patient was admitted to the pediatric intensive care unit (PICU) for further care.  She was initially kept on nothing by mouth (NPO) status. Strict intake and output (I&O) was monitored.  An intravenous (IV) normal saline bolus and continuous IV fluids were given.  The patient was given 20 mg of IV Famotidine every 12 hours (Q12H).  EKGs were done Q6H and neurological checks were done Q1H.  The patient was monitored for seizures and serotonin syndrome. IV Lorazepam was ordered as needed (PRN) for seizures. Psychiatry and Social Work consultations were ordered.  The patient's diet was advanced to a regular diet. She was given 600 mg of oral Ibuprofen for headache.  The patient was placed on 1:1 constant observation, and suicide precautions were maintained.  Her diet was advanced to a regular diet. She was transferred to an inpatient psychiatric unit.    

MCG Drug Ingestion or 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 is required other than observation care.  In this case this patient had an overdose from 24 Lexapro and 8 Ambien and needed to be observed for serotonin syndrome, possible seizures, was on 1:1 suicide observation and suicide precautions as she was considered a high suicide risk due to her recent suicide attempt with intent to end her life in the context of worsened depression and hopelessness which also is a risk factor for suicide, had continuous cardiorespiratory monitoring, EKG's every 6 hours, and neuro checks every 1 hour.  She was considered an imminent danger to self and in need of 24-hour psychiatric hospitalization in addition to medical treatment due to her overdose, so this was considered a severe drug toxicity and not observation care as she was a high suicide risk.  She was considered an imminent danger to self and in need of inpatient hospital treatment then.  This patient required and received active psychiatric treatment in this hospital even though she was on a medical unit as she was followed by Psychiatry and Social Work consultants and was transferred to the Psychiatric Unit for further psychiatric hospital treatment she required hospital treatment even in this medical hospital with psychiatric consultation as she had severe psychiatric symptoms putting herself in imminent danger.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity substantiated.