Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia

Treatment: Inpatient Admission

The insurer denied coverage Inpatient Admission

The denial is Reversed

This adult patient reportedly was admitted to this inpatient hospital setting on for involuntary movements after taking extra Risperidone. It was reported that the patient had a fever, tachycardia, nausea, agitation, more paranoia, and had elevated creatinine kinase (CK) 0.95, low potassium (K) 3.0, magnesium (Mg) and Calcium (Ca) 8.6. The patient reportedly had a diagnosis of Schizophrenia and had past reported auditory hallucinations and also had past depression. The patient reportedly had Becker's Muscular Dystrophy. There was consideration of neuroleptic malignant syndrome in addition to dystonic reaction due to taking too much antipsychotic medication. There also was concern for sepsis. The patient was not cleared psychiatrically. The Risperidone was discontinued and Abilify started. The patient also reportedly had IV (intravenous) fluids, Benadryl, and electrolytes managed. 

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he did not require 24 hour hospital treatment, and they recommended a less restrictive level of care.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment from as the medical records provided enough specific evidence to support that the patient required this level of care then. The Milliman Care Guidelines (MCG) 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 meet criteria for inpatient behavioral health level of care. Also, the American Psychological Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that neuroleptic malignant syndrome is a rare but potentially life threatening side effect of antipsychotic medications and requires inpatient hospital treatment. In this case, it was reported that this patient took too many antipsychotic medications, Risperidone, and had dystonic reaction and rule out neuroleptic malignant syndrome so the patient required inpatient hospital treatment. The patient had medical symptoms including fever, tachycardia, nausea, agitation, more paranoia, and had elevated CK, low K, Mg, and Ca. Symptoms included staring at the walls on admission. The patient also had a history of psychotic and depressive symptoms and one had to rule out suicide attempt for taking too many pills or worsened psychotic symptoms as a cause as there was a past auditory hallucinations and reports of increased paranoia during the hospital stay. The patient had psychiatric consultation and these issues reportedly were being assessed and required inpatient hospital treatment due to the rule out for the potential life threatening neuroleptic malignant syndrome. The patient also needed to be assessed a few days in the hospital to assess if this were a suicide attempt or confusion and inability to care for self-such as taking too many medications resulting in risk to self. After the psychiatric consultant was done and the patient was medically cleared, the patient was discharged. As a result, the recommendation is to reverse the previous decision and approve coverage for continued inpatient hospital treatment.

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission is substantiated.