Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unresponsiveness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of anxiety, depression, and asthma, was brought to the emergency department by her daughter and boyfriend after they found her shaking and unresponsive at home. Upon assessment, the patient was responsive and oriented to person, place, and time. She recalled a vague sequence of events leading to her presentation, including eating, going upstairs, and then experiencing chest and abdominal pressure, a sense of impending doom, and uncontrollable pacing. She also remembered hearing someone speak to her but being unable to respond or move.
In the emergency department (ED), the patient exhibited confusion and a sensation of paralysis and rigidity. 
Despite initially moving her extremities, the patient refused a full neurological and musculoskeletal examination. 
Computed tomography (CT) scans of the head, abdomen, and pelvis displayed no acute intracranial or visceral abnormalities. Due to altered mental status, shaking episodes, and unresponsiveness, the patient was admitted for further evaluation, including consideration of possible seizures and psychiatric causes.
During her hospitalization, the patient was assessed by a psychiatrist who diagnosed adjustment disorder and considered ruling out delusional disorder. However, the patient did not require immediate psychiatric intervention and expressed openness to individual therapy. A magnetic resonance imaging (MRI) scan of the brain and electroencephalogram (EEG) were conducted, both yielding normal results. Throughout her hospital stay, the patient remained clinically stable.
She was discharged to outpatient care with a comprehensive assessment, normal imaging studies, and a diagnosis of adjustment disorder. Further follow-up was recommended to address her psychological symptoms. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care.
The review of the medical records revealed that the patient's symptoms were most likely psychogenic. Having said that, the patient had no signs of psychosis, suicidal or homicidal ideations. The imaging studies including a magnetic resonance imaging (MRI) scan of the brain were unremarkable, and an electroencephalogram (EEG) was not suggestive of seizures.
Even though the patient had a seizure, there was no mention that the patient's seizures were associated with an infectious process such as encephalitis or meningitis. There was no evidence that the seizures were the result of drug toxicity or withdrawal. There was no mention that the patient had any cardiac arrhythmias of immediate concern. The physical exam did not reveal new focal neurologic deficits.
Laboratory evaluation was not consistent with metabolic abnormalities. It was clearly indicated in the notes that during the entire hospital stay the patient remained seizure-free.
There was no mention that the patient had increased intracranial pressure or cerebral edema.