Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, tachycardia.
Treatment: inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This adult patient reportedly was admitted to the hospital due to fever and tachycardia and also reported that she wanted to be admitted as she was not feeling safe at home. The patient had a fever of 101.3 and a heart rate of 139 beats per minute. She was recently discharged from a psychiatric hospital. She reportedly had chronic auditory hallucinations though not command, felt that her family did not want her home, and she felt unsafe. There were no reports of suicidal or homicidal ideation, or worsened psychosis as she reportedly was at her baseline. The patient reportedly had Haldol Decanoate prior to admission and was due for another injection in a few weeks. The patient was seen by the psychiatric consultant who cleared her for medical disposition. The patient was treated with intravenous (IV) fluids, IV antibiotics, IV steroids, and had an infection work up. She was continued on her psychotropic medications of olanzapine and Haldol. The patient was discharged four days later. 

The reviewer agrees with the decision to deny coverage for hospital treatment as the medical records provided did not support that she required acute hospital treatment then. The Milliman Care Guideline (MCG) Behavioral Health-Adult-Inpatient Level of Care guidelines reports that one needs one of the following: presenting as an imminent danger to self, imminent danger to others, severe psychiatric or behavioral symptoms, a severely dysfunctional living including inability to care for self, unwilling to participate voluntarily, or if a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. This patient reportedly was seen by the psychiatric consultant who reported that no acute psychiatric hospitalization was warranted as she was at her baseline and did not have acute distress. They stated that she did not have suicidal, homicidal ideation, intent, or plan, did not have acute psychotic symptoms but rather chronic auditory hallucinations and there were no reports of command auditory hallucinations. It was reported that the hallucinations were non-command, vague, intermittent, a female voice, and that the patient denied visual hallucinations, was not acutely manic or depressed, and did not pose an imminent danger to self or others. She was cleared for medical disposition and no acute psychiatric interventions were needed at that time. There were no further reports of acute psychotic symptoms or danger to self or others throughout the hospital stay. 

There were no reported specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour hospital setting then or that could not be achieved in a less restrictive setting then. Also, there were no records showing specific evidence to support that a less restrictive level of care was not feasible for her condition and symptoms as of then. As a result, the recommendation is to uphold the previous decision and deny coverage for inpatient mental health treatment in this hospital. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.