Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Change In Mental Status and Low Potassium
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This female patient is status post recent laparoscopic cholecystectomy and presented with altered mental status.  Psychiatry was consulted and recommended one to one.  Vital signs revealed the following: temperature 98.5, pulse 100, respiratory rate 18, blood pressure 99/65, and pulse oxygenation 100%.  Exam was remarkable orientation to self and time only.  Labs showed white blood cells (WBC) 11.9, hemoglobin/hematocrit (H/H) 12.4/36, platelet (Plt) 402, sodium (Na) 134, potassium (K) 2.7, blood urea nitrogen/creatinine (BUN/Cr) 3/0.4, glucose 119, lactic acid 2.96, and lipase 495.  Urinalysis (U/A) was positive for ketones, blood, leukocytes, white blood cells (WBC), red blood cells (RBC), bacteria, and epithelial cells.  Urine drug screen was positive benzodiazepine. 

The patient was admitted with metabolic encephalopathy.  Plan was to transfer to psychiatry once medically stable.  Intravenous (IV) antibiotics were stared for urinary tract infection.  Day two, vital signs were stable.  The patient's head computed tomography (CT) was negative.  Potassium was repleted. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was protocol initiated.  Lexapro was started for panic disorder.  On day three, the patient was oriented.  She complained of abdominal pain aggravated by movement.  She has been constipated since the cholecystectomy two weeks ago.  Plan was for an enema.  The patient was is psychiatrically cleared.  On day four, the patient was medically stable.  She was unable to walk due to lower extremity weakness.  Neurology was consulted and magnetic resonance image (MRI) was ordered.  On day five, plan was for magnetic resonance image (MRI), electroencephalography (EEG), and lumbar puncture (LP).  She was unable to perform the EEG due to hair.  On day six, the patient continued to complain of inability to walk.  There was no focal weakness on exam.  Magnetic resonance image (MRI) of the brain and spine were normal.  On day seven, the patient declined lumbar puncture (LP).  She was cleared for discharged.

No, the proposed inpatient hospital admission was not medically necessary.
This patient was admitted with altered mental status.  The patient  was hemodynamically stable and afebrile.  Labs were remarkable for hypokalemia and a urinary tract infection.  Plan was to transfer to psychiatry once medically stable.  She did not have bacteremia.  There is no documentation of electrocardiogram (EKG) changes. She was tolerating oral intake.  Potassium repletion and treatment of the urinary tract infection did not require an acute inpatient level of care.  

During the patient's hospital stay, her mental status improved and she was cleared by psychiatry.  Discharge was delayed after the patient complained of an inability to walk, despite a normal exam.  The patient was clinically stable.  She had not failed a lesser level of care.  She did not require intervention at an acute inpatient level of care.  The proposed inpatient hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.