Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
This adult patient was admitted to this inpatient hospital treatment due to behavioral changes, psychotic decompensation including catatonia, severe agitation, physical aggression including hitting and spitting staff, confusion, lack of responsiveness, inability to answer questions, depressed mood, decreased oral intake, patient was noncompliant with medications which contributed to this psychotic decompensation. The patient had a diagnosis of Schizophrenia. The patient also had multiple medical issues including a fever of 100.9, elevated heart rate of 100, dehydration, lactic acidosis, and systemic inflammatory response syndrome (fever, elevated heart rate, lactate of 3.1, and dehydration). The patient had a recent hospitalization with a discharge the day prior to this admission and had multiple past hospitalizations for similar presentations and psychotic decompensation. The patient was put on 1:1 observation and seen by psychiatry daily. The patient was put back on Abilify and received intramuscular (IM) Ativan, IM Haldol, IM Benadryl, and intravenous (IV) Lorazepam. 

The reviewer disagrees with the decision to deny coverage inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required inpatient hospital treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or under the influence of delusions or hallucinations or who are  unable to care for themselves and need constant supervision or support. Also, the Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. In this case it was reported that this patient had severe psychiatric symptoms resulting in an inability to function and an inability to care for themself and also was considered a danger to others due to their physical aggression by hitting and spitting at others and severe agitation so they was considered in need of inpatient psychiatric hospitalization. This patient was catatonic and unable to respond verbally and was standing facing the wall for long periods of time and was unable to answer questions. It was reported that the patient had behavioral changes, psychotic decompensation including catatonia, severe agitation, physical aggression including hitting and spitting at staff, confusion, lack of responsiveness, inability to answer questions, depressed mood, decreased oral intake as the patient was noncompliant with psychotropic medications which contributed to this psychotic decompensation. The patient was unable to function and considered a danger to others. The patient was also put on 1:1 observation due to their inability to function and a danger to others and was restarted on Abilify and was not psychiatrically cleared until discharge. The patient also was on telemetry monitoring. The patient reportedly was psychiatrically cleared for discharge and was considered hemodynamically stable which is when the patient was discharged with follow-up outpatient mental health treatment. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.