Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Delirium. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The determination is overturned. 

This is a female patient admitted after eloping from the hospital. The patient has a history of chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), and schizophrenia and continues to smoke. She was escorted to the emergency department (ED) and refused vital signs or any assessments. She told the emergency department (ED) team that she went home to smoke a cigarette. On exam, she was described as not ill-appearing and without acute distress. The cardiopulmonary exam showed tachypnea with decreased breath sounds while speaking fast, saying she needed to leave now. She has redness to the left lower extremity with no pain or induration. From a psychiatric point of view, she was inattentive, angry, and impulsive. The emergency department (ED) team requested a readmission to the medical floor, where she eloped from. 1: 1 sitter was ordered. 
The medical team assessed the patient and noted a history of behavioral disturbances with disorganized speech. She was admitted to the hospital with hypoxemia and hypotension many days earlier and treated with vasopressors for a short period. She refused to wear noninvasive positive pressure ventilation or oxygen supplementation by nasal cannula. She was followed by psychiatry. She continued to have hypoxemia, hypotension, and hypercapnia. Cardiology recommended outpatient right heart catheterization. She was awaiting placement at the nursing home when she eloped the previous day. She told the medical team, as well, that she needed to smoke, and that is why she left the hospital. A The medical team stated the patient has no capacity for informed decision-making. Also, documented underlying schizophrenia and dementia prevented her from caring for herself independently. As needed, Haldol, lorazepam, and Benadryl were ordered for agitation. It was also documented that she was due for a Haldol Depo shot. The patient was ordered a nicotine patch for tobacco cravings. The medical team developed a plan to discharge the patient to a long-term care facility.
Psychiatry reassessed the patient and confirmed the lack of capacity to leave against medical advice. The case management notes state the patient was deemed medically stable for discharge; however, no accepting facilities were identified, and the patient remained in the hospital. 
At issue is the medical necessity of inpatient admission. 

Based on the provided documentation, this patient, with schizophrenia and dementia, was deemed to be unsafe, with an inability to care for herself by both psychiatry and internal medicine. A safe discharge could not be established, as no living relatives could provide adequate supervision, nutrition, and assistance with ADLs (activities of daily living) for this patient. Based on behavioral health criteria, the patient has a severe psychiatric illness, with severe cognitive and memory impairment, impulse control, poor judgment, and insight, and therefore requires hospital admission. The elopement is adequate evidence that the patient is unsafe in an unsupervised environment.