Diagnosis: Body Aches and Cough.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male with a history including COPD (chronic obstructive pulmonary disease), HIV (human immunodeficiency virus), and substance abuse disorder. He presented with body aches and productive cough. He was noted to think he was withdrawing from heroin.
The patient's vital signs were remarkable for BP (blood pressure) 167/119. The patient's pertinent labs included WBC (white blood count) 14.6 and sodium 135. Chest x-ray shows cardiomegaly.
Treatment included IV (intravenous) fluids, labetalol, IM (intramuscular) Naloxone, and nebulizer.
The patient was admitted. The next day, he was refusing labs. He complained for lethargy, nausea, diarrhea and abdominal pain. ID (infectious diseases) consultation was performed.
He signed out AMA (against medical advice) on Day #3.
The health plan denied coverage of the admission, noting the patient could have continued work up at an observation level of care. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

This patient with a history of substance abuse was admitted for possible opiate withdrawal. The health plan denied coverage of the admission, noting the patient could have continued work up at an observation level of care. There is no evidence of hemodynamic instability. The patient's labs were remarkable for mild leukocytosis. There was no evidence of infection. Chest x-ray did not show pneumonia. He was admitted for monitoring and further work up. There is no documentation of severe withdrawal that required an inpatient care. He did not receive intervention that required an inpatient level of care and had not failed an observation level of care.
Therefore, given the above, the requested inpatient hospital admission was not medically necessary.