Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular
Inpatient Hospital

This is a patient with a past medical history significant for a drug-induced mood disorder who was initially admitted to a psychiatry unit. Reportedly, the rapid response was called because the patient developed altered mental status. According to the history and physical (H&P) note, while in the psychiatry unit, the patient's mother came to visit her and they had an argument. During the argument, the patient fell and could not talk, and apparently was not responding. When the medicine resident tried to perform a blood draw, she woke up and said that she was feeling fine. When the patient was seen by the admitting attending provider, she was in no acute distress and denied any new complaints. She was afebrile, hemodynamically stable, and had a normal oxygen saturation.
The rest of the physical exam documented in the H&P note was unremarkable. Reportedly an electrocardiogram (EKG) was performed and demonstrated RSR' pattern in lead V1. For that reason, the patient was transferred to a medical floor with a diagnosis of altered mental status. The differential diagnosis included a conversion disorder.
Reportedly, the admitting physician discussed the abnormalities noticed on the EKG with the cardiology attending. According to the cardiologist, the patient had incomplete right bundle branch block, which was not particularly concerning. At the time of the initial evaluation, the patient was found to have lactic acidosis, which according to the admitting attending was a laboratory error. The admitting provider stated that the patient's symptoms were likely behavioral in nature and the patient did not require any further workup.
During the hospital stay, the patient was seen by a psychiatrist who stated that the patient had no suicidal or homicidal ideations, denied any auditory or visual hallucinations, denied feelings of paranoia or anxiety. Therefore, the psychiatrist cleared the patient for discharge.
The health plan's determination is upheld.
This patient appears to have had a syncopal episode that was related to a discussion with her mother. During the rapid response, the patient was hemodynamically stable, and when evaluated by an admitting physician had no specific complaints. At that time she was afebrile, blood pressure was 120/71, heart rate 68, respiratory rate 18, and oxygen saturation 98% on room air.
At the time of admission, the patient was awake, alert, and oriented times three (x3), with no acute distress. A head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The cardiovascular exam was normal. The lungs were clear to auscultation with no wheezing, rales, or rhonchi. The abdominal exam was benign. The rest of the exam was unremarkable.
Laboratory evaluation demonstrated that the white blood cell count was 11, hemoglobin 11.9, and electrolytes were normal except for a low bicarbonate. The note was made in the H&P that patient's bicarbonate value was likely inaccurate due to a delay in the delivery of the sample to the lab.
The patient's EKG demonstrated an incomplete right bundle branch block that was considered to be a benign change that did not prompt further evaluation. The patient was seen by a psychiatrist and had no alarming features justifying admission at the acute inpatient level of care.
The patient had no abnormalities in vital signs including fever, abnormal blood pressure, heart rate, or oxygen saturation. Reportedly, the patient's EKG did not show evidence of any arrhythmias of immediate concern. The possible syncopal episode was not associated with cardiac ischemia, congestive heart failure, severe electrolyte abnormalities, persistent altered mental status, persistent or recurrent seizures, or any other clinical abnormalities justifying admission at an acute inpatient level of care. As far as mental health, there was no evidence of any suicidal or homicidal ideations or any other psychiatric conditions necessitating admission at the acute inpatient level of care.