Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This patient reportedly was admitted to this inpatient hospital due to altered mental status, tachycardia, failure to thrive and dehydration. He reportedly was catatonic, was not responding to questions or commands, not eating or drinking, had confusion, incomprehensible speech, was refusing to shower or get up, had inability to care for basic needs, had urine in his underwear, and he was noncompliant with his medications including his psychotropic medications. He had a diagnosis of schizophrenia and had multiple past reported psychiatric hospitalizations. He reportedly was unemployed and living with his parents and siblings. He reportedly was prescribed Aripiprazole and Escitalopram. He reportedly was given IV (intravenous) fluids and Lorazepam for catatonia and tachycardia. He reportedly was seen by cardiology due to tachycardia. He reportedly was seen by psychiatry who recommended that he be transferred to the psychiatric unit when medically stable. He reportedly was transferred to the psychiatric unit.
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required inpatient hospital treatment then.  The APA (American Psychological Association) 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 MCG (Milliman Care Guidelines) 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 situation 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 himself, so he was considered in need of inpatient psychiatric hospitalization. This patient reportedly was catatonic and unable to communicate or function, was not eating or drinking resulting in failure to thrive and dehydration and tachycardia. He reportedly as a result required hospital treatment. He reportedly was not responding to questions or commands, not eating or drinking, had confusion, incomprehensible speech, was refusing to shower or get up, had inability to care for basic needs, had urine in his underwear, and he was not taking his medications. He had further tachycardia, hypertension, and diaphoresis. When he was medically cleared he was transferred to the psychiatric unit for inpatient mental health hospital treatment. This patient required hospital due to altered mental status, catatonia, and inability to function. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.