Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a medical history of breast cancer status post mastectomy, schizoaffective disorder, hypertension, and sleep apnea on CPAP (continuous positive airway pressure) therapy.
The patient was admitted for lower extremity weakness and fall secondary to drug induced myoclonus due to polypharmacy. The fall was not associated with loss of consciousness, syncope, dizziness, blurry vision, palpitations, or head strike. At baseline, the patient uses a cane/walker for ambulation. The patient was recently seen by her psychiatrist and her medications were changed. However, she inadvertently continued her previously prescribed medications (Prolixin, Celexa, Cogentin) and new medication (Lybalvi) prescribed by the psychiatrist. She was alert, awake and oriented without neurological abnormalities, she did not have any respiratory distress or depression, she was hemodynamically stable without arrhythmias, and she did not require any intravenous medications.

The Inpatient Hospital Admission was not medically necessary.

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient with a medical history of breast cancer status post mastectomy, schizoaffective disorder, hypertension, and sleep apnea on CPAP (continuous positive airway pressure) therapy was admitted for lower extremity weakness and fall secondary to drug induced myoclonus due to polypharmacy. The fall was not associated with loss of consciousness, syncope, dizziness, blurry vision, palpitations, or head strike. At baseline the patient uses a cane/walker for ambulation. The patient was recently seen by her psychiatrist and her medications were changed. However, she inadvertently continued her previously prescribed medications (Prolixin, Celexa, Cogentin) and new medication (Lybalvi) prescribed by the psychiatrist.
The patient was seen by neurology and determined to have weakness and fall secondary to drug induced myoclonus with a recommendation to consult psychiatry to adjust her medications. On the next day, she was seen by psychiatry and the recommendation was to discontinue Prolixin, Celexa, Cogentin and continue only Lybalvi. Per the physiatrist consultant, she was cleared from a psychiatric perspective. As per the clinical documentation throughput the hospitalization, she was hemodynamically stable, had an oxygen saturation greater than [>] 90% on room air and was not in any respiratory distress, she was alert/awake/oriented without documentation of any focal 
neurological abnormalities, she did not have any arrhythmias, severe electrolyte abnormalities or metabolic acidosis, specific finding indicating severe, prolonged or delayed drug toxicity, she did not have any seizures, there was no need for lipid emulsion therapy, intravenous infusion of sodium bicarbonate, anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication and she did not have any other condition, treatment, or monitoring requiring inpatient admission. In addition, she did not require extended stay due to age, she did not have persistent toxic drug levels, hypoglycemia, or complications from the initial drug toxicities or require ongoing antidote treatments.