Appeal type: Medical necessity
Decision: Upheld

Other 
Inpatient Hospital

This is a case of a female, history of major depressive disorder, under the treatment of psychiatry, with prior hospitalizations for depression, who presented to the emergency department with confusion. The patient recently had a dose of Xanax increased by 50% and was started on a new medication Abilify 2 milligrams (mg) daily as well. The patient reportedly under increased stress secondary to work. The patient was having difficult time responding to questions. She was evaluated in the emergency department. Vital signs were stable, with a temperature of 98.6, the blood pressure was 134/84, respiratory rate of 16, and a pulse of 72. The oxygen saturation was 96% on room air. On exam, the patient is awake, avoiding eye contact, no acute distress. The cardiovascular exam is normal. Cranial nerves II through XII are intact, preserved strength in all 4 extremities, and sensation is intact. STAT head computed tomography (CT) was done, which showed no evidence of acute intracranial pathology. Laboratory studies were unremarkable.

The patient was admitted with severe recurrent major depressive disorder without psychotic features, a possible effect from medications. Psychiatric medications were placed on hold. Cerebrovascular accident (CVA) was felt to be unlikely. Internal medicine was consulted on the same day, to evaluate the patient, they agreed with the assessment. They recommended a magnetic resonance imaging (MRI), to definitively rule out CVA. The patient reported no suicidal or homicidal ideation, therefore 1:1 observation was not necessary.
The patient was also evaluated by neurology, who performed a thorough neurologic assessment and found no acute focal abnormalities. They agreed with performing a brain MRI, and also recommended obtaining an electroencephalogram.
The results of the MRI showed no acute abnormality. Urinalysis was done, which showed 6 white blood cells and some leukocyte esterase. On the complete blood count (CBC), the white blood cell count was completely normal. Nevertheless, the patient was started on broad-spectrum antibiotics for questionable urinary tract infection (UTI). Electroencephalogram (EEG) was attempted, the patient could not tolerate. Vital signs remained normal. Psychiatric medications continued to be held. Mental status continued to remain poor, though with the patient is described as being more attentive on this day.
Over the next 2 days, the patient showed improvement in mentation, she ate a meal, communicated with family, but reported not remembering the events of the previous days.  Brain magnetic resonance angiography (MRA) was also done, which showed no evidence of stenosis, or aneurysm.
Over the coming days, the patient's mental status continued to improve, the patient was alert and oriented, pleasant and cooperative, with no significant worsening of the presenting condition. The patient remained in the hospital, before being discharged to a psychiatric inpatient treatment facility.

The health plan's determination is upheld.

The patient presented with acute encephalopathy, hemodynamically stable, without focal neurologic deficits. The patient had a normal laboratory and imaging evaluation in the emergency department. She was seen by psychiatry, as well as by internal medicine, for an evaluation. The patient did not have delirium due to alcohol or sedative withdrawal; the patient did not require life-sustaining interventions such as artificial feeding. Neurology recommended the completion of acute stroke workup with MRI and EEG. MRI was negative. Therefore, acute stroke was ruled out within 24 hours of admission. The patient was treated for a UTI, however did not have a fever, vital sign abnormalities, vomiting, or dehydration. Urinalysis only showed 6 white blood cells (WBCs).  Beyond this, there was no acute need for hospitalization, certainly not at an inpatient level of care. All of the above can be accomplished under a lower  level of care.
In conclusion, an inpatient stay was not medically necessary. The patient could have been treated at a lower level of care status.