Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic psychotic disorder best characterized as schizophrenia
Treatment: Acute inpatient level of care
The insurer denied the acute inpatient level of care.
The denial is overturned.

The case involves an adult male admitted to acute inpatient psychiatric services for treatment of an exacerbation of a chronic psychotic disorder best characterized as schizophrenia, unspecified type, and comorbid general medical conditions with hyperglycemia and metabolic acidosis. The patient has other co-morbid mental health condition best characterized as an unspecified anxiety disorder; general medical comorbidities include type II diabetes mellitus and hypertension. The patient presented to the emergency department brought in by his spouse. He had worsening symptoms of psychosis attributed to the recent second dose of the COVID-19 (coronavirus) vaccine; he presented with a serum glucose above 500 and other laboratory abnormalities including elevated creatine phosphokinase (CPK), low sodium and blood gases indicating a metabolic acidosis and consistent with an acute worsening of the diabetes. 

The patient had been to an emergency department four days earlier with agitation, psychosis and aggressive behavior associated with mood swings. At the time of presentation for evaluation and treatment, the patient was acutely psychotic and demonstrated disorganized thought processing with content that was illogical and incoherent with paranoid thinking impacting his functioning. He reported auditory hallucinations hearing voices in the walls and windows, and anxiety and apprehension with sad affect and suicidal ideation. He also reported somatic sensations indicating that his skin felt "artificial."

He was admitted to acute inpatient level care with combined medical and psychiatric treatment for the comorbid conditions, an exacerbation of the schizophrenia and diabetes. He received one-to-one observation, medication adjustments per the psychiatric consultant and general medical support. He was prescribed intravenous insulin and olanzapine, as well as "as needed" (PRN) use of Haldol for agitation and psychosis. Other medications included enalapril, enoxaparin and metoprolol. During his brief stay, the patient's mental status and functioning had not changed significantly, despite ongoing treatment with antipsychotic medications and other therapeutic interventions to address the hyperglycemia and metabolic disturbance. He continued to display perceptual disturbances and delusions prompting him to call 911 that involved fears that the family pets were at risk. He was intermittently hyper-religious and paranoid with compulsive behaviors associated with motor agitation. He required staff intervention for daily care; he was cooperative with staff and medication adherent. He was deemed to be medically cleared and was transferred for acute inpatient psychiatric services.

The dates under review were denied certification of coverage by the health plan for inpatient level treatment on the basis of medical necessity with reference to InterQual Criteria and the assertion that the patient could have been effectively treated as an outpatient. 

The treatment facility indicated that the inpatient admission and stay was medically necessary on the basis of Milliman Care Guidelines (MCG) Criteria for inpatient level care: Other Psychotic Disorders and Endocrinology/Diabetes, respectively for Inpatient Care (B-011-IP and M-130). Additionally, the appeal letter indicated that the inpatient level care was reasonable and medically necessary in view of the exacerbation of schizophrenia with acute symptoms and decline in functioning, and the general medical comorbidity.

Yes, the proposed treatment was medically necessary for this patient.

The patient's admission and continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) and treatment to address the metabolic disturbance (diabetes) did require the admission and continued inpatient level services, structure, and monitoring through discharge/transfer. The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and treatment issues related to persistent symptoms of acute psychosis with general medical complications were clinical factors and treatment dimensions that necessitated the acute inpatient hospital care, structure, and monitoring. The medication treatment and safety monitoring, the support of functioning and the continued application of general medical treatments for the diabetes and hypertension, as well as assurance of medication adherence, were factors that did warrant the admission and the continued inpatient level treatment through discharge/transfer. 

As the treatment facility asserts in the appeal, the inpatient admission and stay was medically necessary and the inpatient level care was reasonable and medically necessary in view of the exacerbation of schizophrenia with acute symptoms and decline in functioning, and the general medical comorbidity. The health plan's denial is not reasonable in that the patient could not have been safely or effectively managed with lower level services such as outpatient treatment.

Specifically, the patient's admission and continued treatment through discharge/transfer is reasonable and in the best interest of the patient; he had severe symptoms of psychosis complicated by an acute general medical disturbance, a decline in functioning and safety issues together with a high risk for medication non-adherence due to persistent symptoms of psychosis. He had deteriorated to the point that he was a safety risk with disorganized and perceptual disturbance/paranoid thinking and poor insight and impaired judgment that persisted throughout his stay. Again, the patient could not have been safely or effectively managed during the time interval under review at a lower level of care or in a less restrictive treatment environment. The admission and continued stay was necessary to develop a safe and clinically appropriate discharge plan and disposition that would effectively support his continued treatment.

These answers are consistent with the scientific literature and practice guideline, referenced below, as well as with instruction for this NY State mandated review.