The patient has a history of sarcoidosis, breast cancer, pulmonary embolism, anxiety, and complex regional pain syndrome and presented to the hospital with a chief complaint of shortness of breath.

Chest x-ray was negative for acute findings. The patient was admitted for sarcoidosis. The plan of care included intravenous (IV) steroids, bronchodilators, pulmonology consult, cardiology consult, pain management, and continue other home medications. Cardiology saw the patient and requested telemetry and continuation of current medical therapy. Pulmonology recommend a chest computed tomography (CT). The chest CT demonstrated interval mild subpleural reticular changes consistent with inflammatory etiology. Palliative care saw the patient for pain management and compression fracture and adjusted the pain medication. Neurosurgery also saw the patient because of a thoracic vertebral compression fracture and recommended against a surgical intervention. The patient was also started on tizanidine and lidocaine patches for the thoracic compression fracture. A review of the medication history shows that the patient was receiving IV morphine boluses as needed for pain daily through the date of discharge.

The health plan's determination is overturned.

The reason is that while the patient was admitted for a sarcoidosis flare, the patient remained in the hospital because of uncontrolled pain. The patient had a history of complex regional pain syndrome and evidence of a new vertebral fracture and was seen by the pain management service and neurosurgery, and was receiving IV morphine in addition to oral pain medication. Patients with severe pain requiring IV opioid therapy for prolonged periods of time are not typically managed at the outpatient level because of the risk of an adverse event, such as respiratory depression or persistent severe uncontrolled pain.