Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID 19 (Coronavirus 2019), psychotic symptoms

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission.
 
The denial is overturned.

This patient was admitted to this inpatient hospital on the medical unit due to a positive COVID 19 (Coronavirus 2019) test. It was reported that she was seen by psychiatry who had determined that she was in need of psychiatric hospitalization due to worsened psychotic symptoms including disorganized thinking and behavior, confusion, internal preoccupation, increased thought blocking, minimal interaction, poor sleep, and inability to care for her basic needs due to psychotic symptoms. She tested positive for COVID 19 and required medical hospitalization as she was not considered medically cleared for a psychiatric admission. She also reportedly was noncompliant with medications and stopped taking her psychotropic medications after her previous hospitalization. She reportedly had 2 past psychiatric hospitalizations. She reportedly was homeless and estranged from her family. She reportedly was started on Risperidone and was transferred to the psychiatric unit for inpatient psychiatric treatment due to her continued psychotic symptoms and inability to care for her basic needs. She was medically cleared with a negative COVID 19 test and was medically asymptomatic for 2 days and then was medically cleared for psychiatric admission. 
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary. They stated that she did not require hospital treatment.
  
The medical records provided evidence to support that she required inpatient level of care until she was medically cleared for inpatient psychiatric hospital treatment. 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 including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care.

In this case, it was reported that this patient had significant psychiatric symptoms including psychotic symptoms and the inability to adequately care for herself. The APA (American Psychological Association) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment. 

This patient had severe psychiatric symptoms interfering with the ability to care for her basic needs which put herself in danger. She had reports of worsened psychotic symptoms including disorganized thinking and behavior, confusion, internal preoccupation, increased thought blocking, minimal interaction, poor sleep, and the inability to care for her basic needs due to psychotic symptoms and the psychiatrist recommended inpatient psychiatric hospitalization. The psychiatric consultant reported that she continued with psychotic symptoms including internal preoccupation and refusal to engage in the interview as she was lying in bed refusing to answer questions. She was transferred to a psychiatric unit after being medically cleared due to COVID 19. 

This patient required and received active psychiatric treatment in this hospital even though she was on a medical unit. 

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

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