Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety and hyponatremia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with PMH (past medical history) of anxiety. He presented to the ER (emergency room) with complaint of heart racing associated with anxiety and a sense of impending doom when he was at home with his family. 

The patient was interpreted via an interpreter and noted that, "I am going to die" and "please help." He also started some sentences "can you...", but failed to complete the sentence. He soiled himself in the ER and began pacing. His father noted that the patient was drinking a large amount of water and was exercising for some time to treat "fibrillation." He had a similar problem approximately two weeks prior, and was evaluated in the ER and discharged with outpatient follow-up with Behavioral Health, but he failed to do so. 

In the ER, the patient's HR (heart rate) was 127, respiration was 26, BP (blood pressure) was 131/61, Pulse Oximetry was 99 and Temperature was 98.8. The patient was found to be anxious, worried, tangential, preserving his fear of death, and not verbally re-directable. Otherwise, his physical exams were unremarkable. 

The patient's EKG (electrocardiogram) showed sinus tachycardia. His blood work was significant for serum sodium of 122, serum osmolality 251, urine osmolality 57, Potassium 3.1, Bicarbonate 18, WBC (white blood count) 22.98, and TSH (thyroid stimulating hormone) was normal. The patient was admitted for further evaluation and management of hyponatremia and anxiety. 

The patient subsequently underwent cardiology evaluation and had telemonitoring. His cardiac enzymes were normal, and TEE (transesophageal echocardiogram) was planned as an outpatient. His workup for infection, given that he had a Leukocyte count of 22.98, was unremarkable. Further workup including MRI (magnetic resonance image) brain was done that showed a left sellar cyst. Neurology and neurosurgery evaluated the patient and recommended against lumbar puncture, as it was less likely a case of autoimmune encephalitis. The patient was also evaluated by a Psychiatrist, who noted that the patient would not benefit from inpatient psych unit admission, as this was likely a case of anxiety vs somatization disorder vs delusional disorder. 

The patient improved eventually with the management of anxiety and hyponatremia. He also improved with water deprivation as it was thought to be a case of psychogenic polydipsia. He was stable for discharge and the plan was to follow with a Psychiatrist, cardiologist, and endocrinologist as an outpatient. 

Yes, the Inpatient admission was medically necessary.

The patient had a second presentation with severe anxiety and excess water intake with a sense of impending doom. His evaluation in the ER found him to have significant tachycardia of 127 and hyponatremia of 122 along with leukocytosis of 22. The patient had fear of infection in his heart, was in extreme stress/anxiety, and was asking for help. Given that he had leukocytosis and hyponatremia, workup was initiated, and he was started on Lorazepam and maintained on water deprivation as hyponatremia was thought to be due to polydipsia. Further workup, including CT (computerized tomography) and MRI (magnetic resonance image) of the brain was done that showed left sellar cyst. Neurology and neurosurgery evaluated the patient and recommend against lumbar puncture or any intervention, other workups for infection were negative. As per Medscape, patients of hyponatremia with a propensity toward inappropriate free water ingestion should be admitted to a unit where free water access is restricted. Given this clinical scenario, this inpatient admission was a medical necessity.