Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain, Delirium. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 
 
This patient reportedly was admitted to this hospital due to chest pain, shortness of breath, agitation and remained agitated until discharge. The patient reportedly had a significant medical history of coronary artery disease, myocardial infarction, cerebrovascular accident (CVA), upper gastrointestinal bleed due to peptic ulcer, and gastroesophageal reflux disease (GERD). The patient reportedly had a significant psychiatric history for multiple suicide attempts by jumping in front of a train and car, and overdose and had multiple past psychiatric hospitalizations. He had reported psychiatric diagnoses of post-traumatic stress disorder (PTSD) and Major Depressive Disorder. The patient reportedly had intramuscular (IM) Haldol and intravenous (IV) Ativan multiple times and still was agitated and restless. The patient reportedly was seen by the psychiatric consultant who also had reported that the patient had delirium and was too delirious for psychiatric admission and they recommended continued hospital treatment until cleared. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Delirium reports that delirium frequently heralds a medical emergency and patients are usually managed in an acute-care hospital setting. This was the case with this patient. The patient reportedly was seen by the psychiatric consultant who reported that the patient had delirium and was too delirious for psychiatric admission. It was reported that the patient was on constant observation and took Haldol 5 milligrams (mg) IM and IV Ativan 2 mg IV times 2 and still was agitated and restless. It was reported that the patient still was agitated, restless, and wandering, throwing himself on the floor, and kicking their legs up in the air. The patient reportedly had additional Haldol 5 mg IM and Ativan IV 2 mg and 4 mg. The psychiatric consultant recommended Ziprasidone IM and stated that the patient had multiple past suicide attempts. The patient reportedly had jumped in front of a train twice and in front of a car twice and had an overdose attempt once. The patient reportedly had multiple psychiatric admissions. The patient reportedly lacked supports and was homeless for two years and lived in a hotel currently. The patient reportedly witnessed their uncle stab themselves to death and their fiance committed suicide by overdose, and the patient reportedly was held at gunpoint and punched and robbed so they had trauma and PTSD as a diagnosis in addition to Major Depressive Disorder.  Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk of suicide. It also reports that patients with multiple suicide attempts are at higher risk for suicide. This patient had reports of multiple past suicide attempts so was considered a high risk still and with their mental status changes and agitation, the patient was considered unable to function safely outside of this inpatient hospital setting then. The patient required multiple IM and IV medications and still was agitated even despite the maximum amount of Precedex. It was reported by the psychiatric consultant that the patient was cleared for discharge psychiatrically and was discharged then. 

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 the inpatient hospital admission is substantiated.