Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Neuroleptic malignant syndrome (NMS)
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This male Patient was admitted to the hospital and went to the medical intensive care unit (MICU) first due to whole body rigidity, leukocytosis, lactic acidosis, and elevated CPK due to neuroleptic malignant syndrome (NMS) as he reportedly had a recent hospitalization due to psychosis with a diagnosis of Schizophrenia and was taking oral and long-acting Haldol. He also was taking Valproic Acid and Ativan. He reportedly was admitted to the surgical ICU was catatonic and started electroconvulsive therapy (ECT) in addition to taking Ativan and Bromocriptine. He was moved to the medical floor in March 2023.  It was reported that he continued with ECT treatments and Ativan taper for catatonia. It was reported that he had continued waxing and waning of mental status continued with catatonia and still required ECT and benzodiazepines to treat it. It was reported that his cognitive deficits required constant supervision and that he still needed ECT and benzodiazepine treatment for catatonia and mental status/cognitive waxing and waning. It was deemed unsafe for him to return home, and inpatient psychiatric treatment was recommended for continued ECT and benzodiazepine treatment for his catatonia mental status issues and psychiatric medication adjustments. He was discharged from the medical floor to the psychiatric unit.
The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including the inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that neuroleptic malignant syndrome is a rare but potentially life-threatening side effect of antipsychotic medications and requires inpatient hospital treatment. It also reports that hospitalization is indicated for patients who are considered to pose a serious threat of harm to themselves or others, have command auditory hallucinations, bizarre delusions, grossly disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, catatonic symptoms, or who are unable to care for themselves and need constant supervision or support. 

In this case, it was reported that this patient could not care for self or basic needs and still had mental status waxing and waning with cognitive deficits in addition to catatonia and required ECT and benzodiazepine treatment for catatonia and also monitoring for neuroleptic malignant syndrome (NMS). He had multiple serious medical issues during his hospital stay and required MICU and SICU treatment, ECT, Ativan, and Bromocriptine. The hospital course reportedly was complicated by altered mental state (AMS), acute hypoxic respiratory failure, and increased secretions with concern for aspiration intubation and worsening neuroleptic malignant syndrome (NMS). He reportedly had an extensive workup including brain magnetic resonance imaging (MRI) and computed tomography (CT), lumbar puncture studies, and electroencephalogram (EEG) which were all negative except for generalized slowing on his EEG. He reportedly had respiratory failure and had a tracheostomy. He had some reported bleeding from the tracheostomy and also had treatment with IV dexamethasone for upper airway edema. It was reported that he had 17 ECT treatments from February to April and psychiatry was following him and recommended a slow Ativan taper for his catatonia. There reportedly was a meeting with psychiatry, social work, and medicine to determine discharge plans from this medical floor. It was reported that he had continued waxing and waning of mental status continued with catatonia and still required ECT and benzodiazepines to treat it. He reportedly could not function or adequately care for basic needs without 24-hour supervision. It was reported that his cognitive deficits required constant supervision and that he still needed ECT and benzodiazepine treatment for catatonia and mental status/cognitive waxing and waning. It was deemed unsafe for him to return home, and inpatient psychiatric treatment was recommended for continued ECT and benzodiazepine treatment for his catatonia mental status issues and psychiatric medication adjustments. He reportedly was discharged from the medical floor to the psychiatric unit. This patient had severe psychiatric and medical issues and was unable to care for his basic needs he required continued hospital treatment until he was discharged to the psychiatric unit then for further treatment with ECT and benzodiazepines for catatonia and mental status waxing and waning and cognitive deficits and inability to care for his basic needs. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for continued hospital admission is substantiated.