Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This adult patient presented to the emergency department and was admitted to the medical floor as he had multiple medical issues including elevated anion gap, critically low bicarbonate, elevated Blood urea nitrogen (BUN) and creatinine, low sodium, elevated White blood cells (WBC). He had metabolic acidosis, dry mucous membranes, and wheezing, and had altered mental status initially including delusions of snakes on his body, agitation, and disorganization including defecating and urinating on self, and admitted to drinking alcohol and using marijuana, and past crystal methamphetamine use. He reportedly had elevated heart rate of 122. He was on cardiac monitoring, was put on a Clinical Institute Withdrawal Assessment (CIWA) protocol, and 1:1 observation. He was seen by the psychiatric consultant who psychiatrically cleared him for discharge. The patient reportedly was discharged the next day when considered medically cleared. 

The medical records by the psychiatric consultant reported that the patient had normal speech, organized thinking, denied suicidal or homicidal thoughts, denied hallucinations or delusions, was calm and cooperative, had full affect and euthymic mood, had no current delusions of snakes being on his body, adequate insight, judgment, and impulse control, and stated that the patient was not considered a threat of harm to self or others, was not psychotic and was psychiatrically cleared for discharge. It was reported that the patient admitted to alcohol and substance use and did not know what got into him earlier in the morning. 

In this case this patient did not have reports of active severe substance withdrawal symptoms, past complicated withdrawal such as alcohol withdrawal seizures or delirium tremens, and there was no reported acute psychiatric or substance use issues as per the psychiatry consultant note which cleared the patient for discharge psychiatrically. The medical records stated that the patient had medical issues, but the psychiatric consultant saw the patient on the admission day and reported no current altered mental status anymore as was reported earlier in the morning. It was reported that delirium was being considered but the psychiatric consultant reported organized thought process, normal speech, denied suicidal or homicidal thoughts, denied hallucinations or delusions, was calm and cooperative, had full affect and euthymic mood, had no current delusions of snakes being on his body, adequate insight, judgment, and impulse control, and stated that the patient was not considered a threat of harm to self or others, was not psychotic and was psychiatrically cleared for discharge. It was reported that the patient admitted to recent alcohol and substance use but had improved in mental status. It was reported that the patient did not know what got into him earlier in the morning, but he presented without altered mental status for the psychiatric consultant who cleared him for discharge psychiatrically. There were no reports of acute alcohol or substance withdrawal treatment needs in the psychiatric consultant's. There were no reports of specific identifiable or quantifiable treatment objectives or goals that could only be achieved in a 24-hour inpatient psychiatric or detoxification hospital. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission from is not substantiated.