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 male was admitted to this inpatient hospital on due to altered mental status and acute agitation after methamphetamine use. He also had elevated heart rate and elevated temperature of 101.8, and increased creatinine with acute kidney injury. He also reportedly was confused and tried to enter the wrong apartment and was agitated when he could not get in and thought it was her apartment. He also had delayed speech, anxiety, labile affect, paranoia, and hyperactivity. He was also immunocompromised and noncompliant with medication. The patient had major depressive disorder with multiple past suicide attempts. He had an inpatient rehabilitation treatment and had 3 hospital visits since then. There was suspicion of toxic encephalopathy. He required and received intravenous (IV) antibiotics including Ceftriaxone and Vancomycin and also received 2 doses of IV Lorazepam and Haldol. He was seen by addiction psychiatry who did not clear him for discharge until days later.
  
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 meet criteria for inpatient behavioral health level of care. 

The InterQual Behavioral Health-Adult Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others , psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then meet criteria for inpatient treatment. 

This patient had severe symptoms requiring 24-hour hospital treatment including altered mental status and acute agitation after methamphetamine use, paranoia, confusion, delayed speech, anxiety, labile affect, and hyperactivity. He also could not care for his basic needs due to these symptoms. He also reportedly had elevated heart rate and elevated temperature of 101.8, increased creatinine with acute kidney injury and reportedly required and received IV antibiotics including Ceftriaxone and Vancomycin and also received 2 doses of IV Lorazepam and Haldol. He reportedly had a recent inpatient rehabilitation treatment and had 3 hospital visits since then due to similar presentations and also had medical issues including electrolyte imbalance. He had multiple medical issues and altered mental status including confusion with acute agitation and paranoia and was unable to care for his basic needs then and was in need of 24-hour hospital treatment. He also was considered at higher risk for suicide due to multiple past suicide attempts with major depressive disorder and PTSD in addition to his multiple medical issues. He reportedly was seen by addiction psychiatry who did not clear him for discharge days later.  

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

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