Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heroin Overdose
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female who initially presented to the emergency department after being found unresponsive. Her pertinent history included chronic back pain, anxiety, depression, tobacco use, and substance abuse. Initial vitals revealed a temperature of 98.3 degrees Fahrenheit, heart rate (HR) 98, blood pressure (BP) 140/80, respiratory rate (RR) 16 and her peripheral capillary oxygen saturation (SpO2) was 100 percent (%) on room air. The initial examination documented the patient as lethargic with shallow respirations and pinpoints pupils. Narcan was administered with rapid improvement in mentation and breathing patterns. The patient admitted to snorting heroin.
Initial laboratory testing revealed a white blood cell count (WBC) of 18.1, hemoglobin 12.2, glucose 121, blood urea nitrogen (BUN) 19, creatinine 1.74 (Baseline 0.59), creatine kinase (CK) 4139, carbon dioxide (CO2) 18, aspartate aminotransferase (AST) 91, Anion gap 17, and her troponin was 0.754. The urine drug screen positive for cocaine and tetrahydrocannabinol (THC). The electrocardiogram (EKG) revealed sinus rhythm without acute ischemic changes. The chest x-ray (CXR) was unremarkable. The computed tomography (CT) of the thoracic spine was unremarkable. Solid food and water were provided and tolerated. Intravenous fluids were administered. The patient was placed in the hospital thereafter. The admitting physician had an impression of heroin overdose, elevated troponin likely due to demand ischemia (not an infarction), rhabdomyolysis, and acute kidney injury. The treatment plan included telemetry, intravenous fluids, and serial laboratory testing. Repeat laboratory testing noted a worsening creatine kinase to 27,000 but an improved serum creatinine to 1.2.
Nephrology was consulted who had an impression of acute kidney due to rhabdomyolysis in the setting of an overdose. Recommendations were to increase continuous intravenous fluids to 300 cubic centimeters per hour (cc/hr). The patient decided to leave against medical advice later in the day.
Frithsen, et al. published guidelines regarding the evaluation and management of acute poisoning. They note that the initial approach to a person who has been poisoned should be to assess the airway, breathing, and circulation, and to take a thorough history. Evaluation of possible medication poisonings should include basic laboratory studies, such as a complete metabolic profile, to determine electrolyte imbalances and liver and renal function. Most other laboratory studies should be performed based on clinical presentation and history. Ongoing treatment of unstable patients with toxic medication ingestions should focus on correcting hypoxia and acidosis while maintaining adequate circulation. These patients can have rapid decline in mental or hemodynamic status even when they appear to be compensating. Disposition of a person who has been poisoned warrants careful consideration of multiple factors, and those exhibiting signs or symptoms of toxicity must be monitored longer.[1]
The initial evaluation documented the patient as lethargic with shallow breathing and pinpoint pupils consistent with an opioid overdose. Narcan was provided with marked clinical improvement. Parekh et al. note rhabdomyolysis is a potentially life-threatening condition caused by a breakdown of skeletal muscle and the release of the intracellular contents into the circulatory system. There are many possible causes, including crush injury, excessive muscular activity, medications, infections, and varied metabolic, connective tissue, rheumatologic, and endocrine disorders. Optimal crystalloid selection is still debated, but immediate, aggressive intravenous volume expansion is indicated to prevent myoglobinuric renal failure.  

The health plan's determination is overturned in whole.