Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of schizophrenia, alcohol abuse, and substance abuse, who was admitted with a chief complaint of fatigue and headache. The patient reported history of falls at home, without head trauma or loss of consciousness. He denied any chills, nausea, vomiting, shortness of breath, or chest pain. An evaluation in the emergency department (ED) with a head computed tomography (CT) 6 days before this presentation was negative for trauma. The patient is noncompliant with medications and currently only takes Advil.

The medical team admitted the patient with a diagnosis of fatigue and headache, which had resolved. The plan was to continue to monitor. Psychiatry assessed the patient on the day of admission for schizophrenia and noted the patient had been presenting to the emergency department nearly every day for weeks. He gets food, sleeps, and then is being discharged. He stays at a homeless shelter otherwise. They report the patient is at baseline from a psychiatric functioning standpoint and did not necessitate psychiatric inpatient admission. They recommended reevaluating the patient the following morning.

Similarly, over the next 3 days, the patient remained hemodynamically stable, without signs of active hallucinations due to schizophrenia. The plan was unchanged to transition the patient to a skilled nursing facility on discharge. Physical therapy assessed the patient again and found not to be a candidate for an acute skilled nursing facility. When the patient was informed of this, he reported feeling unwell and fatigued, knowing that he would be returning to the shelter. Vital signs remained stable; the physical exam is unchanged and normal during this time.

The subject under review is the medical necessity for the inpatient stay.

The health service/treatment of inpatient medical stay is not necessary for this patient. The patient was admitted to the hospital for placement, as documented by the admitting team, and subsequent progress notes. The principal diagnosis was headache and fatigue, without trauma or loss of consciousness. There was no evidence of vasculitis, intracranial bleed, stroke, dural sinus thrombosis, or intractable symptoms. The patient was cleared from a psychiatric standpoint within 24 hours of presentation. The rest of the hospital stay was trying to determine the patient's placement to a skilled nursing facility, as he was uncomfortable returning to the homeless shelter.
Based on medical necessity, no acute medical needs warranted this patient to be maintained in the hospital setting, under inpatient level of care. It was reasonable to admit the patient for monitoring until cleared by psychiatry, however this could have been done at a lower level of care status. The vital signs remained stable throughout the length of stay. Laboratory studies were normal. The patient was not exhibiting any hallucinations or response to internal stimuli based on schizophrenia. The patient had no suicidal or homicidal ideation. Imaging was negative for any abnormalities. There is no indication for inpatient medical hospitalization.