Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status (AMS). 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is modified. 

This patient was admitted to this hospital due to altered mental status (AMS) including confusion and disorientation. He reportedly had a seizure due to alcohol withdrawal as he had been reportedly drinking 1 pint of vodka twice per week. He reportedly was not able to recall immediate events and had short term memory loss and an ataxic gait. His troponin initially was elevated at .13 and there was concern for demand ischemia. His EKG (electrocardiogram) revealed prolonged QTc (interval on a EKG) and biphasic T waves (interval on a EKG) in anterolateral leads. His EEG (electroencephalogram) revealed focal cerebral dysfunction in the left temporal region. He reportedly had a medical history significant for coronary artery and cerebrovascular disease. He was agitated, aggressive, disruptive, difficult to redirect and security was called. The patient was given Haldol/Lorazepam/Diphenhydramine IV (intravenously). He reportedly had psychiatric and cardiology consultants and social work was involved in discharge planning. He was discharged to his apartment without services.
 
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that he had altered mental status initially but the delay in discharge was due to pending placement. 
  
The chart notes provided enough evidence to support that the patient required hospital treatment part of his stay. The APA (American Psychiatric Association) 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. 

The MCG (Milliman Care Guidelines) 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. 

Notes reported that the patient was frustrated that he had been in the hospital for over one month without interventions and that the social worker was pursuing applications for social security benefits for assisted living placement. It also stated that an alternative was single site facility with residential aids who could assist in 
medical appointments, and that he had potential for referral to the ACT (Assertive Community Treatment) team, which could provide adequate support for safe discharge. Notes reported that his apartment was locked by the police due to a roommate's death. Notes reported that he was awaiting placement. Notes reported that he was pending discharge home with services when his apartment was cleaned. The patient was discharged to this apartment home without services. 

The recommendation is to modify the previous decision and approve partial coverage for inpatient hospital treatment. 

The health plan did not act reasonably 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 for inpatient hospital treatment is demonstrated.