Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid withdrawal
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.
 
This adult was admitted to this inpatient hospital setting originally on telemetry and then medicine as he had a prolonged QTc [interval on an electrocardiogram (ECG)] of 595, had opioid withdrawal symptoms including muscle aches, malaise, severe fatigue, generalized weakness, an elevated heart rate of 90, chills, and yawning. He reportedly had acute dehydration likely due to poor oral intake, electrolyte abnormalities, elevated liver function tests (LFTs), acute renal injury with elevated creatinine, low sodium, low potassium and chloride. He was given intravenous (IV) fluids. It was reported that the elevated QTc was likely due to drug intoxication. He was at risk for opioid withdrawal as he was using Fentanyl and drinking alcohol. He had severe metabolic alkalosis. He had alcohol hepatitis. He took Diphenhydramine and Olanzapine and was prescribed Lorazepam as needed for withdrawal. It was reported that he was in the emergency room (ER) of another hospital that day earlier and was released. He continued with prolonged QTc, acute renal injury, and hypokalemia until he was transferred to the medical floor. The plan was for him to go to an inpatient substance rehabilitation upon discharge but there were no beds available, so he had to wait another day until an inpatient substance rehabilitation bed became available which is when he was discharged.

The medical records provided enough specific evidence to support that he was considered a high risk medically and at risk for severe opioid withdrawal and overdose due to his fentanyl and alcohol use. 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. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

The medical records supported that he did require 24-hour medical hospital treatment for opioid detoxification management and medical treatment and it was considered unsafe for him to be treated in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his multiple serious medical issues in addition to substance use and opiate issues. 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 the inpatient hospital admission is substantiated.