Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status
Treatment inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

The patient was admitted to the hospital due to altered mental status. The final adverse determination letter states that the admission was denied because the patient did not have unstable vital signs that did not improve, finding of a new stroke on imaging with severe stroke symptoms, and/or need for blood clot busting medication.

The emergency department (ED) note states the patient presented with suicidal ideation (SI). The patient has history of stroke with residual left-sided weakness. The assessment is SI with no physical complaint. Vitals stable and no signs of new stroke were noted.

The social work discharge note states that no home services are recommended. The inpatient discharge summary states the patient had altered behavior. The patient had SI. The exam was with no abnormality, and the patient had a cryptogenic acute/subacute parietal lobe infarct.

The Neurology note indicates acute/subacute parietal lobe infarct. The neurologic exam showed no abnormality.

The magnetic resonance imaging (MRI) brain and magnetic resonance angiography (MRA) showed no evidence of acute stroke. The cardiology consult notes the patient had no negative finding. The psychiatry initial consult states the patient had no negative feelings.
There was no documentation of unstable vital signs that did not improve, finding of a new stroke on imaging with severe stroke symptoms, need for blood clot busting medication, seizure, and/or paralysis. The acute admission was not medically necessary.

Per Sanello, A., et al., (2018), "Several studies demonstrated cardiac etiologies of AMS (altered mental status) in the general population were infrequent, suggesting that a routine 12-lead ECG (electrocardiography) would not be helpful. However, if a dysrhythmia was noted on the cardiac monitor, obtaining a 12-lead ECG was useful to clarify the rhythm. In aged populations, there is a higher prevalence of cardiac causes of AMS, such as myocardial infarction (MI), complete heart block. This suggests that for the elderly population with AMS there may be a benefit in obtaining a 12-lead ECG. Lastly, if an overdose is suspected with medications known to cause cardiac toxicity, such as antipsychotics, sodium channel blockers (tricyclic antidepressants ([TCAs]), diphenhydramine, beta-blockers (BB) and calcium channel blockers (CCB), consider obtaining a 12-lead ECG."

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care." (American Health Information Management Association, 2018).

The inpatient admission is not medically necessary for this patient. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.