Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia and delusions 
Treatment: Inpatient hospital stay 

The insurer denied coverage for inpatient hospital stay. The denial is reversed. 

This patient is a female with a history of schizophrenia, depression, hyperlipidemia, hypertension and diabetes mellitus was admitted for hyperglycemia and delusions. On arrival to the hospital, the patient's glucose level was elevated at 392, and the patient reported not taking her diabetic medications for the last few months. The patient had poor insight of her diabetes diagnosis and the need to take her medication. The patient also reported paranoid delusions that her neighbors were doing witchcraft all day and night, as well as suicidal and depressive symptoms. The patient reported that she did not feel safe at home, and had a past suicide attempt with a knife and had access to knives. The patient was on Haldol, Ziprasidone for psychotic symptoms and Celexa for depression. On exam, the patient's blood pressure was elevated at 180/96 with tachycardia of 94. The patient was referred to the hospital directly from her psychiatric office visit due to the provider's concern that this patient did not have the capacity to understand her medical illness, diabetes and the importance of taking her medications. Consistent with this provider's concerns, the patient's blood glucose level was elevated at 392 with an HgA1c of 14.4. Due to this patient's unstable psychiatric symptoms, the patient is noncompliant to her medical management of her diabetes and was at a high risk for hyperglycemic crisis. The patient presented psychiatric concerns of delusions, psychosis and possible suicidal ideation that required inpatient psychiatric facility transfer after medical stabilization. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment. Also the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide. In this case, this patient presented with active psychiatric symptoms that were interfering with her ability to care for her basic medical needs. The patient reported active paranoid delusional thinking with suicidal ideation and depression. The patient stopped taking her medically necessary diabetes medications, and did not have the capacity to understand the extent of her medical condition, and the need to take her medication to prevent hyperglycemic complications. Consistent with this patient's poor compliance, the patient's glucose on finger stick was significantly elevated at 392. The patient was at danger to self, due to her poor insight and unstable psychiatric status. The patient's past history of suicide attempt with a knife and this patient's feeling unsafe at home with her active psychiatric symptoms put this patient at high risk for suicide. The patient was considered a high risk patient, and was in need of 24 hour hospital treatment. 

Based on the review of the medical record and literature, the patient required the hospital stay as the patient had active and severe psychiatric symptoms and was unable to care for her medical needs. This patient required and received active psychiatric treatment in this hospital even though she was on a medical unit as she was transferred to the psychiatric unit for further psychiatric hospital treatment. 

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

The carrier's denial of coverage for inpatient hospital stay should be reversed. The medical necessity is substantiated.