Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status.
Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay.
The denial is upheld.

The patient had a history of chronic obstructive pulmonary disease and hypertension.  The patient endorsed 2-day history of altered mental status and urinary incontinence.  He reported difficulty walking with his walker.  He was admitted to the hospital one week prior following a fall.  He had an acute kidney injury secondary to rhabdomyolysis.  Computed tomography of the head revealed age-appropriate atrophy.  Magnetic resonance imaging of the brain revealed no significant findings.  Magnetic resonance imaging of the lumbar spine revealed neuroforaminal narrowing at L (lumbar) 4-5 that was most advanced in the left and facet arthrosis that was most advanced at lumbar (L)5-sacral (S)1 with a small facet synovial cyst.  There was a plan to admit the patient to the medical floor.  Neurology recommended a psychology evaluation and urology evaluation.  The patient's review of systems was positive for difficulty urinating, urinary urgency, and weakness.  The patient was not diaphoretic.  His pulmonary effort was normal.  He had an old vertical incision midline of the abdomen that was well-healed.  There was no edema in the lower extremities.  He was alert and oriented to person, place, and time.  His sensation was grossly intact.  He had 5 out of 5 strength in the bilateral upper and lower extremities.  There was no leukocytosis.  His lab work was unremarkable.  His troponin was improved from baseline.  There were no electrocardiographic changes.  Vital signs on the patient noted a blood pressure of 148/101, pulse of 77, temperature of 98.7, and height of 18.  It was recommended that patient be admitted for evaluation of unsteady gait and urinary incontinence.  It was reported that the patient had left foot strength of 2 out of 5.  The patient was noted to have fluctuating left lower extremity motor deficit and fluctuating facial motor deficits.  A lumbar puncture was planned.  The family decided to take the patient to a different facility against medical advice.

Per the Milliman Care Guidelines (MCG) Guidelines, admission is recommended for a mental status change when there is airway compromise, acute or worsening mental status change in a patient with pre-existing known intracranial process, evidence of metabolic encephalopathy, etiology suspected that requires treatment beyond observation care time frame, and delirium.  Inpatient treatment for neurological findings when there is aphasia that is new or progressive, weakness that is progressive or severe noting inpatient care due to functional disability and concerns for safety, paralysis, spasticity, amnesia that is severe and causing functional disability, and for other severe neurological findings not treatable at alternative levels of care.  In this case, the patient presented to the hospital secondary to altered mental status and urinary incontinence.  During his stay, he was noted to have fluctuating left lower extremity motor deficit and fluctuating facial motor deficits.  His initial diagnostic work-up was unrevealing.  There was a plan for a lumbar puncture.  It was argued that the inpatient stay was medically necessary.  However, the documentation did not identify a pre-existing intracranial process, evidence of metabolic encephalopathy, mental status changes or weakness that were causing severe functional disability, or symptoms that would require more than observation care time frame.  

As such, the inpatient stay did not meet MCG criteria, and was not medically necessary.  The patient's care could have been completed at a lower level of care.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is upheld. Medical Necessity is not substantiated.