Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Catatonia.

Treatment full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is modified.

This is the case of a male patient who was admitted due to weakness, fatigue, and catatonia as he was not speaking or communicating, had mutism, slow movements with psychomotor retardation, poor sleep, anxiety, and had medical issues including respiratory alkalosis, increased lactate, increased heart and respiratory rate, and elevated blood pressure. He reportedly had stressors including the separation from his partner and felt overwhelmed. He reportedly had a past psychiatric hospitalization. The patient was seen by the psychiatry consultant. He was started on Ativan to target catatonia and also put on Lithium and was diagnosed with bipolar disorder as a cause for catatonia. The patient first tried Aripiprazole, but he reportedly felt foggy and not like himself when taking that. The plan was to admit him to psychiatry due to his catatonia, when medically cleared. He improved and was discharged without a psychiatric admission.
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. 

Notes reported that he still was taking Ativan 2 milligrams (mg) three times per day (TID) to target catatonia and was making progress, remains altered from baseline, has an increased risk of inability to care for self, has thought disorganization, and required further observation and treatment in this inpatient hospital until medically cleared for admission to psychiatry. 

Notes reported that he was still not able to provide clear answers to questions and was not cleared psychiatrically for discharge as he was still considered at an acute elevated risk due to catatonia. Ativan reportedly was being tapered to 2 mg twice per day (BID). 

Notes reported ongoing abnormalities and he had thought disorganization and was still not yet cleared for discharge and was awaiting transfer to the psychiatric unit, and he was still being treated with Ativan. He still had reports of acute psychiatric symptoms, catatonia, which interfered with his ability to function, communicate, or adequately care for his basic needs, so he required 24-hour hospital treatment until then. 

However, later notes reported that he was taking Lithium in addition to Ativan and was stable without recurrence of catatonia and was not acutely manic or psychotic or demonstrating acute safety concerns so he could ultimately be discharged prior to availability of a psychiatric bed. 

The medical records supported that he no longer had acute psychiatric symptoms and had no further catatonia and was not in need of psychiatric hospitalization then. 

Other notes show that he felt like his normal self, had no psychomotor abnormalities, had euthymic mood, no delusions, no internal preoccupation or perceptual disturbances, was alert and oriented to person, place, and time, and had fair insight and judgment. He reportedly was discharge. 

The medical records provided enough specific evidence to support that the patient required 24-hour hospital treatment from earlier admission but not from later admission. As a result, coverage for inpatient hospital treatment from earlier admission was medically necessary but coverage from later admission was not medically necessary.

The health care plan acted reasonably in part and with sound medical judgment and in the best interest of the patient. The hospital admission from earlier is considered medically necessary for this patient. Continuous admission from later was not.

The insurer's denial of coverage for the full hospital admission is modified.