Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mechanical fall and altered mental status.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a past medical history significant for anxiety, depression, and recent pulmonary embolism being treated with Eliquis who presented to the emergency department after she had a fall. The patient was walking upstairs and tripped on the steps. The patient stated that it was a mechanical fall and denied any chest pain, shortness of breath, or lightheadedness before the fall occurred. The patient did not remember how she got to the hospital and seemed to be confused initially. The patient's daughter said that the patient had been hospitalized several times recently because "her body stiffened up" and the patient seemed to be increasingly forgetful recently.

The patient was admitted to the hospital with a mechanical fall and altered mental status. The admitting physician wanted to rule out metabolic causes, stroke, and decompensated psychiatric disorder. Other clinical conditions included hypokalemia and hyponatremia. The patient empirically was anemic, but her hemoglobin was stable compared to previous.
While in the hospital, the patient was seen by the trauma surgery service. There was no need for intervention.
The patient was also seen by a neurologist. The neurologist stated the patient used Xanax for a long time but ran out of this medication shortly before this event. It was suggested that the confusion could be related to possible head injury versus side effects of tramadol, which could cause seizures, or Xanax withdrawal.
The patient was seen by a psychiatrist who recommended restoring some of the psychiatric medications including Xanax, Abilify, Cymbalta, and Amitriptyline but holding Wellbutrin.
During the hospital stay, the patient's acute encephalopathy resolved. The electrolyte abnormalities including hypokalemia were corrected.
The patient was discharged home.

The health plan's determination is upheld in whole.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
At the time of the initial evaluation, the patient was awake and alert. She was hemodynamically stable and had no signs of central nervous system (CNS) infection. There was no evidence that she had focal neurologic signs. Per history, she had only one single episode of seizure on the day of admission. The imaging studies did not show any acute abnormalities that required intervention.
There was no evidence that the patient had significant electrolyte abnormalities that triggered seizures or encephalopathy. The hyponatremia and hypokalemia were relatively mild.
There was no evidence that the patient had any unstable concomitant conditions that would necessitate admission at the acute inpatient level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
Regardless of the etiology of the altered mental status, the patient's clinical condition improved relatively fast. Therefore, the patient could have been managed safely at a lower level of care status.