Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Starvation ketosis and anorexia with acute psychosis

Treatment: Inpatient admission 

The insurer denied coverage for inpatient hospital treatment. The denial was reversed. 

This female was admitted to the medical hospital as she had starvation ketosis and anorexia with acute psychosis.  She reportedly was not eating or drinking for several days prior to admission, had command auditory hallucinations telling her not to eat or drink, paranoid delusional thinking including thinking people were trying to poison and kill her, and sleeping problems.  She had elevated blood pressure.  She had mental status changes.  She had diabetes and dementia also. She reportedly took IV fluids, B 12, and insulin.  She reportedly was taking Trazodone and Klonopin but was started on Zyprexa and Remeron.  She reportedly was transferred to the Psychiatric Unit.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment.  She had reports of active paranoid delusional thinking including thinking people were trying to poison and kill her, command auditory hallucinations telling her not to eat or drink which interfered with her ability to adequately care for her basic needs, and she did not have the ability to care for her basic needs and did not have the capacity to understand the extent of her condition.  She also had diabetes and with her mental status changes including acute psychosis with starvation ketosis and anorexia, she was considered a danger to self and unable to care for her basic needs.  

Notes also reported continued auditory hallucinations and paranoid delusional thinking including thinking people were trying to poison and kill her.  Notes reported continued psychotic symptoms.  Notes reported that she still had paranoid and bizarre delusional thinking and auditory hallucinations with internal preoccupation, and she had impoverished thought process.  She still was considered to have acute psychosis which put her at risk of danger to self and unable to care for basic needs which required further hospital treatment.  She reportedly was transferred to the psychiatric unit for further hospital treatment so she required the hospitalization as she had active and severe psychiatric symptoms and was unable to care for her basic needs putting herself in danger.  This patient required and received active psychiatric treatment in this hospital even though she was on a medical unit as she was transferred to the psychiatric unit for further psychiatric hospital treatment.  She required hospital treatment even in this medical hospital as she continued with severe psychiatric symptoms including acute psychosis requiring hospital treatment. 

Hospital treatment was medically necessary.  It did not appear that the health care plan acted reasonably or had sound medical judgment, or acted in the best interests of the patient.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.