Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of poorly controlled schizophrenia, diabetes, history of metastatic prostate cancer and noncompliance with treatment. He was initially hospitalized at an inpatient psychiatric unit for nine days, and was transferred to the     medical unit, and admitted under medicine secondary to laboratory abnormalities including hyponatremia and hyperkalemia. The patient had been admitted to the psychiatric service, due to the inability to care for himself, a generally disheveled appearance. The patient exhibited ideas of grandiosity and was treated with antipsychotic medications. His sodium level on admission was 133 with a potassium of 4.9, the white blood cell count was 11.7 and hemoglobin was 8.7. The patient also complained of some pain in the left knee. tooo

A medical work-up was initiated to include a check of urine electrolytes, urine osmolality and urine creatinine. The patient was placed on a 1.5 liter (L) fluid restriction, and salt tablets were provided. Thyroid function tests were checked as part of the hyponatremia work-up. Medications, which can cause hyponatremia, were stopped. The primary impression was that the hyponatremia and hyperkalemia were caused by either drugs or decreased oral intake. Multiple consultants were involved in the patient's care, including nephrology, cardiology, hematology, and neurology. In addition, orthopedic surgery was asked to evaluate for left knee pain and difficulty walking. An x-ray of the knee showed no evidence of a fracture or dislocation. A magnetic resonance imaging (MRI) scan of the knee was ordered. A head computed tomography (CT) scan was also done , which showed old lacunar infarcts, but nothing acute. There are also diffuse microvascular changes. A twelve-lead electrocardiogram (EKG) showed a left anterior fascicular block and incomplete right bundle branch block, with a relatively normal QT interval. On exam, the patient was alert, oriented times three (x3), pleasant and cooperative with a tendency to exaggerate. He was poorly nourished. The cardiovascular exam did not show any significant abnormalities. The psychiatry team continued to monitor the patient throughout the hospital stay. 

The patient did not exhibit any seizure activity. The patient remained on 1.5 L fluid restriction, as well as salt tablets. Neurology evaluated the patient, due to laboratory test obtained by psychiatry, for rapid plasma reagin (RPR), which came back positive. A lumbar puncture was performed to check for syphilis, and the results came back negative. The patient worked with physical therapy, to increase ambulation and improved knee pain. 

The disposition plan was to transfer the patient to the psychiatry unit for ongoing psychiatric needs. On this day, the psychiatrist cleared the patient from inpatient psychiatric care, as there was no evidence of suicidal or homicidal ideation. Outpatient resources were established. However, the patient remained hospitalized at the same level of care refusing any blood work, and described as stable, while an appropriate disposition was being sought by the case managers and social workers. He continued to work with physical therapy, and based on the progress notes, had no complaints. The health plan's determination is upheld. Care could have been provided at a lower level of care. 

The patient had mild hyponatremia and questionable hyperkalemia, as there was hemolysis on multiple samples. He responded well to fluid restriction and salt tablets. The patient was at very low risk for seizures and did not have any mental status changes of consequence, to raise suspicion for developing seizures or coma. 
On the day of transfer, the patient's sodium levels were 131, with an unknown baseline. They slightly trended down to less than 130, down to 129 over the next 48 hours, in the monitored setting. These were not deemed to be uncorrectable. The provided documentation does not support a condition of delirium, obtundation, or coma. There were no seizures; there was no alteration of mental status, he did not appear volume overloaded. The patient was described as alert and oriented, with grandiose ideas, but otherwise stable. The potassium levels were hemolyzed and did not require significant treatment, such as renal replacement therapy, to correct them. 

The patient was undergoing a dementia workup, which is almost never indicated in the inpatient setting. Based on the documentation provided, it was done while the patient was hospitalized, rather than for an urgency factor. 

The majority of the hospital stay was spent in determining the disposition for this patient, as he was cleared by the psychiatry team from inpatient psychiatric hospitalization, having no suicidal or homicidal ideation, improved thought process and calm thoughts. Outpatient resources were provided and the patient was cleared for discharge from their standpoint. 

In conclusion, an inpatient stay was not medically necessary.