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 case involves a patient with a subject for review for the denial of coverage for hospital admission. In the emergency department (ED), the patient was positive for gait problems, dizziness, and lethargy. An electrocardiogram did not support ST-elevation myocardial infarction (STEMI). The patient's vital signs were: blood pressure (BP) 165/63, pulse (P) 70, temperature (T) 36.5 degrees Celsius (C), respiratory rate (RR) 20, oxygen (O2) saturation 99 percent (%). The patient was given fluids and intravenous (IV) antibiotics and was placed on a cardiac monitor. While in a computed tomography (CT) scan, the patient reported visual hallucinations, was drowsy, and was unable to hold a conversation. 

The patient ate without difficulty that same day and returned to their usual self. The patient had been afebrile, oriented to name and year, and speech was fluent and non-dysarthric. Antibiotics and antivirals were discontinued. 

The patient was seen the following day and reported no further events. The patient had difficulty sleeping, but the speech was fluent and non-dysarthric. The patient was oriented and able to spell "world" backward. The patient was noted to be able to stand independently and take several steps unassisted. 

The next day, the physician saw the patient, and discharge management services were discussed, including a final examination with noteworthy findings of awake and alert with a non-focal neurological exam and able to ambulate; discussion of the case and review of the patient's electroencephalogram (EEG) was done. 

A letter of appeal was submitted for the patient, who was brought to the ED via ambulance from work due to drowsiness and gait instability. The physical exam was notable for mental status changes, drowsiness requiring repeated vocal or tactile stimuli to attend to the examiner, dozing off, orientation to self, place, and date, and ability to state name and repeat. The patient was not oriented to the situation or could follow simple and two-step commands. An electrocardiogram (EKG) showed 1st degree atrioventricular (AV) block. A chest x-ray (CXR) was normal, the CT head showed no evidence of a hemorrhage, and magnetic resonance imaging (MRI) of the brain was unremarkable. The patient was admitted to neurology for altered mental status and slightly worsening encephalopathy. Empiric meningitis/encephalitis coverage was continued with Vancomycin, Cefepime, and Acyclovir with no steroids. With the rapid resolution of symptoms, infectious etiology was in doubt. Continuous EEG monitoring was planned, and urine toxicology was unrevealing. EEG monitoring showed activity with occasional left frontotemporal sharps, which were not clearly epileptiform and excessive beta activity, which can be seen with Benzodiazepines or Barbiturates with no seizures captured. Per their wife, the patient returned to baseline and appeared back to baseline. Overnight, with persistent unexplained lethargy, there was some concern for meningitis versus encephalitis; however, given a return to baseline and afebrile throughout, the patient was clinically stable for discharge. 

The Milliman Care Guidelines (MCG) criteria indicate admission if the confusional state persists despite appropriate treatment. According to the records, the patient had a rapid resolution of symptoms, and infectious etiology was in doubt. As such, the denial of coverage for hospital admission is upheld and is considered not medically necessary. The service could have been provided at a lower level of care, such as in outpatient care, the emergency department, or observation care. 

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

The medical necessity for hospital admission is not substantiated.