Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status, toxic encephalopathy,
history of polysubstance abuse, hypertension,
chronic kidney disease
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The case involves an adult female who was brought to the emergency department for erratic behavior in the context of an overdose with crack cocaine; the patient was obtunded, but indicated that she got some "bad dope." She was noted to be drowsy, but arousable with evidence for a chronic mental disorder. History was unable to be obtained due to her altered mental status and symptoms related to the underlying diagnosis of toxic encephalopathy. She was evaluated and stabilized in the emergency department with intravenous (IV) fluids with electrolyte replacement, administration of Haldol and Ativan, and use of other medications to support cardiac, renal and pulmonary functions. She was then admitted to acute inpatient level services with telemetry with transfer to a general medical unit with psychiatric consultation. Diagnoses included polysubstance use disorder with alcohol use disorder in remission, cocaine use disorder and tobacco dependence. She had presented with elevated blood pressure and acute renal failure with rhabdomyolysis with underlying chronic kidney disease and hypertension, as well as history of a seizure disorder and stroke and asthma with associated treatments including atorvastatin, nifedipine and albuterol inhaler. She had a chronic and persistent mental illness with a co-occurring psychiatric diagnosis of bipolar mood disorder with no current treatment.

The patient was admitted to the acute inpatient level care, as noted, with general medical supports and combined medical and psychiatric treatment for the comorbid conditions with a primary diagnosis of toxic encephalopathy due to complications of the crack cocaine overdose. She received observation, medication and general medical support, and quickly stabilized. Evaluation had included laboratory assessments, electrocardiogram (EKG) with telemetry, chest x-ray and computed tomography (CT) scan of the head. She had normal sinus rhythm with cardiomegaly without heart failure related to hypertension, and right upper lobe atelectasis, as well as complications of the rhabdomyolysis and renal failure at the time of presentation. She was prescribed Procardia and aspirin, as well as as needed use of Haldol and Ativan for agitation. During the remainder of her inpatient stay to discharge, the patient's mental status and functioning had improved significantly as her physiologic status improved to baseline. She was cooperative with staff and medication adherent without complications. She received counseling and education regarding the substance use disorder during her stay and at the time of discharge with follow-up to occur with a primary care physician and pulmonary specialist, and was to return home.

Denial Reason: The dates under review were denied certification of coverage by the health plan for inpatient level treatment on the basis of medical necessity with reference to Milliman Care Guidelines, and the assertion that inpatient level services were not medically necessary as no serious complications had occurred such as tear of the aorta, myocardial infarction, stroke, renal failure or seizures. 

Appeal: The treatment facility indicated that the inpatient admission and stay was medically necessary on the basis of Milliman Care Guidelines for inpatient level care: Neurology.

No, the proposed inpatient admission was not medically necessary.
In this case, the patient could have been effectively treated at a lower level of care following observation and stabilization in the emergency department or in an observation unit. The patient's underlying treatment for the toxic encephalopathy (delirium) related to severe cocaine use disorder was amenable to treatment in a less restrictive treatment setting, as indicated on appeal. As the health plan asserts in the denial determination, the patient had no general medical complications that warranted inpatient admission and treatment, as well as no psychiatric or neurologic signs or symptoms that would have required an inpatient hospital level of care. Any indicated cardiac monitoring and serial monitoring of laboratory assessments and other assessments of the kidney injury, cardiac status and treatment of the underlying pulmonary disease could have been appropriately managed at a lower level of care with referral for the underlying substance use disorder with cocaine as well as clinically appropriate follow-up for management of the co-occurring bipolar mood disorder.

This answer is consistent with prevailing standards of medical practice and with the scientific literature and published guidelines (referenced below) pertaining to the evaluation and treatment of the complications of crack cocaine overdose and the underlying substance use disorder, as in this case, These answers are in keeping with New York State instruction for medical necessity review including the application of New York State Office of Addiction Services and Supports (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.

The health plan denied the entire hospital stay and reasonably indicated that the patient had no serious complications that occurred such as tear of the aorta, myocardial infarction, stroke, renal failure or seizures, as well as no psychiatric or neurologic signs or symptoms that would have required an inpatient hospital level of care.