Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient days. 
The denial is overturned in whole.

The patient is a female with a history of Wolfram syndrome, insulin-dependent diabetes mellitus (IDDM), progressive vision loss, anxiety, and obsessive-compulsive disorder (OCD) who was sent from her Adolescent Medicine provider's office to the emergency room (ER) due to outpatient treatment failure of anorexia. She was diagnosed with anorexia 4 years ago. She was noted to have heart rate (HR) in the 60s and orthostatic tachycardia at her appointment. She notably had a 30 pound weight loss in 3 months. In the ER her electrocardiogram (EKG) showed sinus bradycardia. 

She was admitted to the hospital given failed outpatient treatment. She was kept on bedrest except for bathroom, 1:1. She was placed on telemetry to monitor her bradycardia. Weight was less than (<) 1 percentile. Throughout her stay she was assigned a 1:1 without exception, her parents were unable to substitute. This was to monitor for purging or treatment interfering behaviors. She was seen by child psychiatry, adolescent medicine, endocrinology and nutrition. She became agitated and requested papers to leave the hospital against medical advice (AMA). They were eventually able to calm the patient. Over the course of the admission weight increased from 36.7 kg to 40.8kg which was from 65% to 72.3% ideal body weight (IBW). Psychiatry, on initial assessment, felt she did not demonstrate capacity to leave against medical advice, posed significant danger to herself if discharged, and would benefit from inpatient psychiatric hospitalization once medically stable. She was not deemed psychiatrically safe for discharge. They attempted to increase her dose of Zyprexa while admitted, but the dose had to be decreased to her usual dose as she had worsening of her orthostatic vital signs and new abdominal discomfort. Reportedly patient had issue with orthostatic blood pressure changes throughout the admission which resolved on the day of discharge. Notes reveal patient's weight gain was slow but consistent. She was cleared for discharge after she gained greater than (>)70% IBW and her orthostatic blood pressure issues resolved. The subject under review is the medical necessity for the denied dates of inpatient stay. 

The health plan's determination is overturned in whole.

The inpatient stay for the denied dates of service was medically necessary for this patient. She was sent to the hospital via Emergency Medical Services (EMS) as she refused again in her Adolescent Medicine specialist's office. Upon presentation, the patient was < 70% of her ideal body weight and was deemed a significant danger to herself if she were to be discharged. She was failing outpatient management for her condition and met Milliman Care Guidelines (MCG) criteria for inpatient level of care to medically stabilize her condition prior to considering outpatient treatment again. Throughout her admission she demonstrated hypotension as well as orthostatic changes. She required 1:1 close observation to ensure that she consumed her calories, did not attempt excessive exercise nor attempt purging activities in the bathroom. Her progress notes daily continued to document hypotension as well as psychiatry documenting that she was not safe for discharge from a psychiatric standpoint. The patient refused inpatient eating disorder clinic placement which demonstrated her poor motivation to recover. She exhibited hesitancy to advance her calories during the admission and her weight gain was slow. For these reasons, it is clear that she was not a candidate for outpatient care and inpatient level of care was medically necessary.