Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This adult patient went to the hospital and was seen in the Emergency Department (ED) due to a manic episode in which the patient had altered mental status, psychomotor agitation, illogical speech and thinking, responding to internal stimuli, laughing to self inappropriately, was difficult to redirect, did not answer questions appropriately, had poor insight and judgment, had not slept in two days, and had medical issues including an elevated heart rate of 130 and elevated blood pressure, fever of unknown origin, and starvation ketoacidosis. The patient was seen by psychiatry who recommended a one to one (1:1) due to the manic symptoms and inability to care for self or function, and medication were recommended as the patient was reportedly taking Wellbutrin and Lexapro. It was reported that this was the patient's first manic episode. The patient was given intravenous (IV) Haldol and Versed, IV fluids, and was discharged to the psychiatric unit for psychiatric inpatient treatment.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required hospital treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs need hospital treatment. It also reports that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or who are unable to care for themselves and need constant supervision or support. This was the case with this patient as the patient had active manic symptoms and was in a manic episode as the patient had altered mental status, psychomotor agitation, illogical speech and thinking, responding to internal stimuli, laughing to self inappropriately, and was difficult to redirect, did not answer questions appropriately, had poor insight and judgment, had not slept in two days and this required inpatient hospital treatment. The patient also had medical issues including an elevated heart rate of 130 and elevated blood pressure, fever of unknown origin, and starvation ketoacidosis. The patient required medical hospital admission until cleared medically for psychiatric admission. The patient could not be treated in a less restrictive level of care prior to the psychiatric hospitalization as the patient was in an active manic episode and could not function or care for basic needs as a result. 

The 1:1 was not a sitter for observation but was needed because the patient was in an active manic episode with altered mental status and illogical thinking and behavior and could not adequately care for basic needs which required hospital treatment. Even though it was a medical hospital, the patient still required psychiatric care and treatment including the 1:1 for the safety and basic care, not observation only. The patient still required hospital treatment in the medical hospital until the transfer to the psychiatric unit. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.