Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug ingestion.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This teenager was admitted to inpatient hospital treatment after presenting to the emergency department (ED) due to an acute dystonic reaction likely due to an illicit substance as he reported taking pills which he thought were benzodiazepines and was drinking large amounts of vodka. He was sweating, tachycardic, had shortness of breath, restless legs, and had arching of his back, and rhabdomyolysis with a very elevated Creatinine kinase (CK) of 1322 and his bicarbonate was 20.4. He was given Ativan and Benadryl and his dystonia resolved but he still reportedly was at risk for alcohol withdrawal due to his large amount of alcohol use and he was sweating, tachycardic, and had restless legs which could have been related to alcohol withdrawal. He was considered at risk of more severe withdrawal due to his large amount of vodka use and illicit drug use and had comorbid medical issues of dystonia related to illicit drug use and rhabdomyolysis with very elevated CK of 1322 with shortness of breath. He was discharged.
  
The insurer denied coverage for inpatient hospital treatment stating that he did not require 24-hour inpatient hospital treatment, and they recommended a less restrictive level of care.
  
The medical records provided enough specific evidence to support that he was considered a medical risk and in need of inpatient medical hospital treatment. 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. 

It was reported that an illicit drug, that he thought was a benzodiazepine/cocaine, was likely responsible for the dystonic reaction and shortness of breath as well as rhabdomyolysis with a very elevated CK of 1322, and he also had been reportedly drinking large amounts of vodka and had elevated heart rate, sweats, restlessness, and was put on telemetry monitoring, Intravenous (IV) fluids, Ativan and Benadryl was given with relief of the dystonia. He reportedly was at risk for severe, complicated, or life-threatening withdrawal due to the large amount of alcohol use. He was considered a medical risk due to his acute medical problems and was considered in need of 24-hour inpatient hospital treatment. It was not reasonable for him to be treated outside of a hospital setting due to these reasons. He was considered a risk for worsened medical issues due to illicit substance use resulting in medical issues and also was considered at risk for severe, complicated, or life-threatening withdrawal due to his large amount of alcohol use and he had reports of sweats, elevated heart rate, and vomiting and shortness of breath in addition to dystonia and rhabdomyolysis. It was not considered safe for him to be treated in a less restrictive setting other than this hospital setting, and this inpatient hospital treatment was considered medically necessary treatment and not just observational care.  

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.