Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status secondary to encephalopathy and polysubstance abuse
Treatment: Continued Inpatient admission
The insurer denied coverage for Continued Inpatient admission.
The denial is Upheld.

The patient is an adult seeking coverage for continued inpatient stay with a history of human immunodeficiency virus (HIV), stroke, and lung cancer status-post radiation completion. The patient had a 3-day history of fluctuating mental status secondary to possible seizures after taking heroin. Per the patient's spouse, the patient was speaking gibberish a few times a day or making illogical sentences. The patient had been having chronic headaches, vertigo, and brain fogginess. The patient had also gained 40 pounds in the last few months. The patient was admitted for altered mental status secondary to encephalopathy and polysubstance abuse. The patient's spouse had given the patient Methadone and the patient had taken more than prescribed Baclofen. Head computed tomography (CT) scan showed chronic right middle cerebral artery territory infarction with no acute process. Neurology consulted and recommended magnetic resonance imaging (MRI) and electroencephalogram (EEG). Admission chest radiographic image (CXR) showed interval opacification of the right lung apex with redemonstration of adjacent calcified granulomas suggesting pleural thickening. This could reflect progression pleuroparenchymal scarring. 24-hour video EEG showed diffuse slow background representing chronic changes of no acute findings. On admission day 2, the patient had a change in mental status and was not verbally responsive. Stroke code was called. Imaging showed no significant changes. A swallow evaluation was completed. The patient was changed to a pureed diet. Urine toxicology was positive for polysubstance. The patient was positive for trichomonas and started on Flagyl and Keppra. The patient's mentation improved and was recommended for subacute rehabilitation. Social services note indicated that the patient and spouse determined that the patient wanted to go home instead of to subacute rehabilitation. The patient had been accepted to skilled nursing facility. This facility was called, and it was advised that the patient could go. The family was advised that it would be difficult to get certified home health aide services as a home discharge would not be considered safe. There was a plan to follow-up with the patient. The patient indicated that they would start a Methadone program following discharge. 

Per the cited references, admission to the hospital is indicated for patients with mental status change that requires inpatient care when there is acute or worsening mental status change in the patient with pre-existing known intracranial process such as mass, recent stroke, hemorrhage, or previous traumatic injury or when etiology is suspected that requires treatment beyond observation care timeframe. Discharge to a lower level of care is indicated for patients when mental status is at baseline or stable, when neurological deficits are absent or stable and appropriate for the next level of care, when there is no infection, when respiratory status is acceptable, when activity level is acceptable, when intake is acceptable, and when there are no inpatient interventions needed.  In this case, the patient was admitted to the hospital with altered mental status.  The patient had been medically cleared for discharge. There had been a plan for discharge to a skilled facility, but this was deferred due to patient preference. The documentation did not identify acute care needs that would make continuation of inpatient hospital treatment medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the continued inpatient stay is not substantiated.