Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute psychotic symptoms 

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial reversed.

This patient is a male who was admitted to this hospital as he had a heart rate of 149 and blood pressure of 134/108 with a BUN of 42 and creatinine of 2.65 and he was on telemetry and received intravenous (IV) fluids and was on 1:1 as he was psychotic.  He had a positive toxicology for cocaine and Methadone.  He had auditory and visual hallucinations, disorganized thinking and behavior, agitation, persecutory delusional thinking, irrational behavior, and reportedly was using IV cocaine and heroin, Methadone, pills off the street, and alcohol.  He had a diagnosis of Schizoaffective Disorder and substance use disorders.  He was seen by the Psychiatry consultant who recommended psychiatric hospitalization when medically cleared but there were no beds available until when he was transferred to the Psychiatric unit. The insurer denied coverage for inpatient hospital treatment.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as he had acute psychotic symptoms reported from a specified range requiring 24 hour hospital treatment.  He was not safe to be treated outside of a 24 hour hospital as he was not able to function or care for his basic needs.  He had reports of auditory and visual hallucinations, disorganized thinking and behavior, agitation, persecutory delusional thinking, irrational behavior, and reportedly was using intravenous (IV) cocaine and heroin, Methadone, pills off the street, and alcohol.  

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, or aggression are in need of hospital treatment.  In this case he had reports of hallucinations, delusional and disorganized thinking and behavior, and inability to care for his basic needs. Notes on a specified date reported auditory and visual hallucinations, disorganized thinking and behavior, agitation, persecutory delusional thinking, and irrational behavior. Notes on another date reported that he was agitated overnight and pulled out his IV as he was hallucinating with delusions and psychiatry recommended physical and chemical restraints. Notes on the day after reported that he still had auditory hallucinations and delusions. Notes on the next day reported that he had auditory hallucinations and was talking to himself and still had paranoid delusions.  Notes on the following day reported that he had hallucinations, delusional thinking, and needed inpatient psychiatric hospital treatment when the bed was available.  He had command auditory hallucinations telling him to go.  He still had reports of paranoid delusional thinking, internal preoccupation, and Risperidone was increased.    
Other notes reported that he was very disorganized, trying to get out of bed and drink toilet water, had a thought disorder, was agitated, and IM Ativan was given and mitten restraints and he still required 24 hour psychiatric hospital treatment. Notes on the final date reported that he was still having auditory hallucinations, paranoid delusional thinking, internal preoccupation, and was isolative, and he was transferred to the psychiatric unit.  He had acute psychotic symptoms requiring 24 hour hospital treatment then. 

As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment.  It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.

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