17yo. With 5-Day INPT Stay For Acute Psychosis

Submitted by Alyssa Riley, MD, FAPP
Physician Advisor, Dell Children’s Medical Group 

Type of Denial: Medical Necessity Concurrent
Age: 17 years
Genders: Female
Insurance: Medicaid Replacement
Length of Stay: 5 days
Reason for being Hospitalized: 17 yr old female hospitalized for acute psychosis, with new onset hallucinations and agitation, following weeks of social withdrawal and sleep disturbances.
Pertinent Past Medical or Maternal History: Depression

Hospital Course:

Pt underwent evaluation for ingestion, primary psychiatric disorder, and autoimmune or other encephalopathy for new onset agitation and hallucinations. She had unremarkable vital signs and physical exam, normal labs (chemistry, hepatitis, thyroid, STDs, UDS), and normal CNS studies (head CT, EEG, and brain MRI). Due to persistent agitation, she required oral and intravenous anxiolytics. She was evaluated by psychiatry, who initiated anti-psychotic therapy. Patient was discharged to an inpatient psychiatric unit for additional care. 

Appeal Strategy:

This denial was overturned via peer to peer discussion, demonstrating patient required ongoing care with PRN intravenous anxiolytic therapy.

Editor’s Comment: Key to overturning this denial on peer to peer is to emphasize that patient’s psychosis and agitation was refractory to initial treatment.