Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is modified.

This patient was admitted to this inpatient hospital in the medical unit due to altered mental status and inability to care for basic needs. She was found naked in the street lying in her feces, had hallucinations, delusional thinking in that she was talking with God when sleeping, disorganized thinking and behavior, difficulty thinking, agitation, erratic behavior, noncompliance with medication, and she was not eating or drinking. She was severely dehydrated with rhabdomyolysis. She reportedly was overusing Ambien. She had intravenous (IV) fluids, Trazodone, Haldol as needed, corrective insulin, Gabapentin, and a lidocaine patch. She had uncontrolled hypertension, diabetes, gangrene, and spastic diplegia. She had psychiatric and neurological consultations and had delirium. The disposition was for her to be discharged to an inpatient rehabilitation facility but left against medical advice (AMA). 

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that she had no brain infarction or a new stroke. They stated that she did not require 24-hour hospital treatment and they recommended a less restrictive level of care.
  
The MCG - Milliman Criteria Guidelines for Psychiatric Disorder: Common Complications and Conclusions reports that one meets criteria for hospitalization if one is a danger to self or others and not manageable at a lower level of care, if they have severe behavioral health issues such as hallucinations, or if a less restrictive level of care is not considered feasible until acute intervention is done. This was the case with this patient as she was considered to have severe psychiatric symptoms. She was severely dehydrated with rhabdomyolysis. She had psychiatric and neurological consultations and had a diagnosis of delirium and still had multiple medical issues including severe dehydration, rhabdomyolysis, uncontrolled hypertension, needed corrective insulin, IV fluids, and medications for agitation and pain. Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Delirium reports that delirium frequently heralds a medical emergency and patients are usually managed in an acute-care hospital setting and patients with altered mental status are candidates for inpatient hospital treatment. This patient had a change in mental status and could not care for her basic needs and was considered a danger to self as a result as she was not eating or drinking or taking medications appropriately and was found in the street naked lying-in feces, and she had a diagnosis of delirium. 

Notes reported that she had recent proximal muscle weakness and mechanical falls and the neurology consult recommended a brain magnetic resonance imaging (MRI) and also stated that she had cerebral palsy. Notes reported that the disposition was for substance abuse rehab (SAR) placement, and she was no longer considered to have acute care needs and was placed on alternate level of care (ALOC) status awaiting placement to the SAR placement. Notes reported that she was psychiatrically cleared for discharge as well. Notes reported that she left AMA prior to placement in an SAR placement. 

The patient presented with acute mental status changes and inability to function. It did not appear that the health care plan acted reasonably or in the best interests of the patient for the initial days but did act reasonably and with sound medical judgment for the extended stay.

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

The insurer's denial of coverage for the inpatient admission is modified. Medical necessity is partially substantiated.