Diagnosis: Overdose
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The proposed treatment was not medically necessary. The patient was clinically stable and had a limited plan of care anticipated for him.

Following this patient's ED evaluation, he was clinically stable. He was lethargic but had normal vital signs. There was no concern that he could not protect his airway. At no point was hypotensive. His symptoms were attributed to drug overdose. His testing in the ED had been unremarkable. The patient was kept in the hospital because he remained lethargic in the ED. The admission note for this patient indicates that he would be kept on a cardiac monitor until his mental status normalized. He would be observed for signs of drug withdrawal. No other testing was anticipated for the patient according to the admission note. At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an observation level of care would have been appropriate.

The patient had no severity of illness to warrant an inpatient admission. He had alteration of mental status, but a CT scan was normal and his blood work was normal. His altered mental status was attributed to drug overdose. No additional testing was planned to look for other potential causes of altered mental status. He had stable vital signs and was protecting his airway.

The patient had no intensity of services to warrant an inpatient admission. He would be kept on a cardiac monitor until his mental status normalized. No additional testing was planned for the patient. He ultimately required a psychiatric evaluation due to agitation that was likely related to drug withdrawal.

In conclusion, the patient was clinically stable following his ED evaluation. A limited plan of care was anticipated for him. An observation level of care would have been appropriate for the patient. The Health Plan acted reasonably in denying coverage for this inpatient admission.