ModifiedCurativePolicy CHP-IP-2026-070

A070. Delirium and Acute Altered Mental Status

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Medical-necessity criteria for acute inpatient admission, observation, level of care, continued stay, and discharge readiness for adults with delirium or acute altered mental status caused by medical, metabolic, or toxic conditions across Curative commercial plans.

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ModifiedCurativePolicy CHP-IP-2026-070

A070. Delirium and Acute Altered Mental Status

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Policy Summary

PayerCurative

PolicyA070. Delirium and Acute Altered Mental Status

Policy CodePolicy CHP-IP-2026-070

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument baseline cognition, repeated delirium screening, the underlying cause and response to treatment, nonpharmacologic measures, and discharge status.

SourceLink

POLICY UPDATE CHANGES

Routine antipsychotic or benzodiazepine treatment is not recommended, and prior fixed haloperidol and quetiapine dosing has been removed.

Prior fixed haloperidol and quetiapine dosing was removed from the delirium management approach.

Admission determination is based on the severity of the underlying cause or safety needs rather than the delirium label alone.

Adults 18+Applicable population

24 hoursContinued-stay review

24–48 hoursObservation window

GCS ≤8ICU threshold

CAMScreening tool

Medical Necessity and Level-of-Care Criteria

Observation or outpatient level

Emergency department care or observation, generally up to 24 to 48 hours, is appropriate when ANY of the following applies and no inpatient admission criterion is met.

Observation or outpatient management

Rapidly reversible cause: A clear, rapidly reversible cause is improving toward baseline, such as corrected hypoglycemia, medication effect, mild dehydration, or an uncomplicated urinary infection treatable orally.Improvement expected within 24–48 hours
Mild delirium with safe support: Mild delirium is manageable with a reliable caregiver; the member can take oral fluids and medications, and outpatient follow-up is arranged.
No acute cognitive change: Chronic cognitive impairment is unchanged from the documented baseline and does not represent delirium.

Intensive care unit

ICU care is appropriate when ANY of the following is present.

ICU level of care

Airway or ventilation compromise: GCS is 8 or lower, the member cannot protect the airway, or mechanical ventilation is required.GCS ≤8
Status epilepticus is present, including nonconvulsive status documented on EEG.
Septic shock or vasopressor requirement: Septic shock is present or vasopressor support is required.
Severe agitation requiring continuous IV sedation: Severe agitation requires continuous IV sedation.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following is present.

Frequent neurologic checks: Fluctuating consciousness with GCS 9 to 12 requires neurologic checks every 1 to 2 hours.GCS 9–12; checks every 1–2 hours
Severe electrolyte abnormality: Severe hyponatremia below 120 mEq/L or hypercalcemia under active correction requires frequent laboratory monitoring.Sodium <120 mEq/L
IV antipsychotic monitoring: IV antipsychotic use with QTc monitoring is required for severe agitation.

Medical-surgical unit

A medical-surgical unit is appropriate when ANY of the following is present.

Medical-surgical level

Identified cause under treatment: Delirium has an identified cause that is under treatment, with stable vital signs.
Nonpharmacologic delirium care: Multicomponent nonpharmacologic delirium care is being provided with screening each shift.Every-shift screening

Discharge readiness

Discharge is appropriate when ALL of the following are met.

Underlying cause managed: The underlying cause is identified and treated, or treatment can continue at a lower level of care.
Cognition improved or at baseline: The member is CAM-negative or cognition is improving toward the documented baseline for at least 24 hours; residual mild inattention may persist.At least 24 hours
No acute safety events: There have been no acute safety events, including falls, need for a sitter, restraints, or parenteral sedatives, for at least 24 hours.At least 24 hours

Continued-stay criteria

Continued stay is medically necessary when ANY of the following is documented and is reviewed every 24 hours.

Continued stay

Delirium not improving: Delirium is not improving despite treatment, the cause is not yet identified, and expanded evaluation is underway, such as MRI, EEG, or lumbar puncture.
Ongoing hospital-level treatment: The underlying cause still requires IV or other hospital-level treatment.
Ongoing safety risk requires continuous observation or parenteral medication was required within the prior 24 hours.Parenteral medication within prior 24 hours
Unable to take oral therapy: The member is unable to take oral intake or medications.

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review.

Chronic stable dementia or behavioral symptoms alone: Admission is requested for chronic stable dementia without acute change, or for behavioral symptoms of dementia alone.
Awaiting long-term-care placement: Continued stay is requested after the underlying cause has resolved and the member is at baseline, solely while awaiting long-term-care placement.
Route to physician review and discharge planning; authorized days are not retroactively denied.
Routine antipsychotic administration: Continued stay is requested solely for scheduled antipsychotic administration to treat delirium in a calm member.
Routine antipsychotic treatment is not supported for delirium.

Chronic stable dementia without acute change and primary psychiatric disorders are outside this policy. When a specific medical cause of acute altered mental status is identified, the applicable condition-specific policy also applies.

For Curative commercial plans, the Medicare two-midnight benchmark is not a coverage criterion. Coverage determinations are based on the applicable medical-necessity criteria and the member’s benefit plan.

The expected length of stay is a planning benchmark, not a limit on covered days. Continued-stay review applies to each period, and days already authorized are not retroactively denied.

Chronic stable dementia without acute change, or behavioral symptoms of dementia alone, is not an acute medical condition under this policy and does not support acute inpatient medical necessity. Such requests are referred for physician review rather than denied by an automated system or non-physician reviewer.

A continued stay after the underlying cause has resolved and the member has returned to baseline while awaiting long-term-care placement is considered custodial or awaiting placement. The case is routed to physician review and discharge planning; authorized days are not retroactively denied.

A continued stay solely for scheduled antipsychotic administration to treat delirium in a calm member is not supported. Routine antipsychotic treatment is not recommended for delirium.

Diagnosis, Revenue, and Clinical Thresholds

ICD-10-CM: delirium and altered mental statusICD-10

F05	Delirium due to known physiological condition
R41.0	Disorientation, unspecified
R41.82	Altered mental status, unspecified
R40.20	Unspecified coma

ICD-10-CM: encephalopathyICD-10

G93.40	Encephalopathy, unspecified
G93.41	Metabolic encephalopathy
G93.49	Other encephalopathy

MS-DRG (FY2027 v44)Revenue

080	MS-DRG FY2027 v44
081	MS-DRG FY2027 v44
884	MS-DRG FY2027 v44
070	MS-DRG FY2027 v44
071	MS-DRG FY2027 v44
072	MS-DRG FY2027 v44
947	MS-DRG FY2027 v44
948	MS-DRG FY2027 v44

Revenue codesRevenue

0120	Revenue code
0250	Revenue code
0300	Revenue code
0350	Revenue code
0610	Revenue code
0920	Revenue code

Glasgow Coma Scale

Inpatient thresholdGCS 13 or lower, or a decline of 2 or more points from baseline

ICU thresholdGCS 8 or lower

Clinical useSupports inpatient admission when present as a clinical severity finding; GCS 8 or lower supports ICU-level care

Serum sodium

Lower thresholdSerum sodium below 125 mEq/L

Upper thresholdSerum sodium above 155 mEq/L

Documentation, Review, and Denial-Risk Guidance

Denial Risk

Physician Review Required for Adverse Determinations

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination. An adverse determination requires review by a licensed physician of the same or similar specialty, after offering the requesting provider a peer-to-peer discussion; the physician must also meet applicable licensure, specialty, and medical-director requirements for the plan’s situs state.

Requests that do not meet criteria must be referred for physician review rather than denied by an automated system or non-physician reviewer.
The absence of a criterion addressing a service is not, by itself, a basis for an adverse determination; a physician applies generally accepted standards of medical practice.
Concurrent review applies to each continued-stay period. Previously authorized days are not retroactively denied; expected length of stay is a planning benchmark, not a limit on covered days.

Documentation Required

Required Clinical Documentation

Clinical Context

Delirium is an acute, fluctuating disturbance of attention and awareness caused by an underlying medical condition, medication, or substance. Management focuses on identifying and treating the precipitating cause and using multicomponent nonpharmacologic interventions, including reorientation, sleep promotion, early mobilization, sensory aids, hydration, and avoidance of restraints and deliriogenic medications. CAM and CAM-ICU are validated screening tools; routine antipsychotic or benzodiazepine treatment is discouraged except when severe agitation threatens safety or prevents essential care.

Clinical Definitions and Planning Benchmarks

CAM-positive delirium

Onset and courseAcute onset and fluctuating course

Required featureInattention

Additional featureEither disorganized thinking or altered level of consciousness

Hypoactive delirium

Motor activityReduced motor activity

AlertnessReduced alertness

Clinical significanceOften missed and associated with worse outcomes

Policy Summary

PayerCurative

PolicyA070. Delirium and Acute Altered Mental Status

Policy CodePolicy CHP-IP-2026-070

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument baseline cognition, repeated delirium screening, the underlying cause and response to treatment, nonpharmacologic measures, and discharge status.

SourceLink

On This Page

Oral intake and medications tolerated:

Oral intake and medications are tolerated; deliriogenic medications are stopped or reduced, and any antipsychotic started in the hospital has a stop plan.

Safe discharge plan: The discharge environment is safe, caregiver supervision is available if cognition is not at baseline, and follow-up is arranged within 1 to 2 weeks to reassess cognition.Follow-up within 1–2 weeks

Applicable levelEither threshold supports inpatient admission when the underlying cause requires hospital treatment

Severe hyponatremia

ThresholdSerum sodium below 120 mEq/L

Applicable levelStep-down or intermediate care

Monitoring contextSevere hyponatremia is listed among conditions requiring frequent laboratory monitoring

Serum calcium

ThresholdSerum calcium above 13 mg/dL

Applicable levelInpatient admission

Clinical contextThe elevation must represent an underlying cause requiring hospital treatment

Oxygen saturation

ThresholdOxygen saturation below 90%

Applicable levelInpatient admission

Clinical contextHypoxemia is an underlying cause requiring hospital treatment

Hypercapnia

ThresholdpH below 7.30

Applicable levelInpatient admission

Clinical contextHypercapnia is an underlying cause requiring hospital treatment

qSOFA

ThresholdqSOFA 2 or more

Applicable levelSepsis-related inpatient admission

Clinical contextSepsis is an underlying cause requiring hospital treatment

Serum lactate

ThresholdSerum lactate above 2 mmol/L

Applicable levelSepsis-related inpatient admission

Clinical contextSepsis is an underlying cause requiring hospital treatment

Observation period

Typical durationGenerally up to 24 to 48 hours

Appropriate levelEmergency department care or observation

When usedAppropriate when no inpatient admission criterion is met and a rapidly reversible cause is improving toward baseline

Neurologic and safety assessments

Assessment frequencyAt least every 4 hours

Delirium screeningEach shift

PurposeFrequent neurologic and safety assessments are a hospital-level service supporting inpatient admission

Neurologic checks

Check frequencyEvery 1 to 2 hours

Clinical indicationFluctuating level of consciousness

GCS rangeGCS 9 to 12

Cognitive improvement before discharge

Required statusCAM-negative or cognition improving toward documented baseline

DurationFor at least 24 hours

Permitted residual findingResidual mild inattention may persist

Absence of acute safety events

Required durationAt least 24 hours without acute safety events

Events assessedFalls, need for a sitter, restraints, or parenteral sedatives

Discharge roleAbsence of these events is required for discharge readiness

Submit clinical documentation establishing the member’s baseline cognition and function, the delirium screening tool and result, evaluation of precipitants, treatment response, and the member’s current clinical support needs.

Baseline cognition and function from family, a caregiver, or records.
CAM, CAM-ICU, or 4AT result, repeated each shift.
Evaluation for medication, infection, metabolic, structural, withdrawal, retention, and pain-related precipitants.
Treatment of the underlying cause and response to treatment.
Nonpharmacologic measures, restraint use, and any antipsychotic or sedative with its indication.
Discharge cognitive status, caregiver plan, and follow-up arrangements.

Documentation Required

Admission and Continued-Stay Support

Support an inpatient admission or continued stay with a documented qualifying severity finding, a required hospital-level service, and an unresolved cause or ongoing hospital-level treatment need. Continued stay is reviewed every 24 hours and is medically necessary when delirium is not improving with an unidentified cause and expanded evaluation underway, the cause still requires hospital-level treatment, ongoing safety risk requires continuous observation or parenteral medication within the prior 24 hours, or the member cannot take oral intake or medications.

Qualifying severity may include persistent CAM/CAM-ICU/4AT-positive delirium after initial emergency-department treatment; GCS 13 or lower or a decline of at least 2 points from baseline; a cause requiring hospital treatment such as sepsis, major electrolyte or glucose abnormality, hypoxemia, hypercapnia with pH below 7.30, uremia, or hepatic encephalopathy grade 2 or higher; a suspected structural, infectious, or seizure cause requiring urgent evaluation; or inability to maintain safety at home or a lower level of care without a safe caregiver alternative.
Hospital-level services may include IV treatment, outpatient-infeasible diagnostics such as lumbar puncture, EEG, or MRI, neurologic and safety assessments at least every 4 hours with delirium screening each shift, or continuous observation for severe agitation with safety risk.
Document the unresolved cause, expanded evaluation such as MRI, EEG, or lumbar puncture, IV or other hospital-level treatment, recent safety risk or parenteral medication, and inability to take oral intake or medications when applicable.

Documentation Required

Discharge Readiness Documentation

Discharge is appropriate only when the underlying cause has been identified and treated or can be managed at a lower level of care, cognition is CAM-negative or improving toward documented baseline for at least 24 hours, and there have been no acute safety events for at least 24 hours.

Residual mild inattention may persist if cognition is improving toward baseline.
The member must tolerate oral intake and medications; deliriogenic medications should be stopped or reduced, and any inpatient-started antipsychotic must have a stop plan.
Document a safe discharge environment, caregiver supervision when cognition is not at baseline, and follow-up within 1 to 2 weeks to reassess cognition.

Documentation Required

Support the Requested Amount and Duration

Requests must include documentation supporting the requested quantity, units, and duration. When a service meets criteria but the request exceeds what the documentation supports, approve the supported portion and refer only the excess increment for review.

Concurrent review applies to each continued-stay period.
Previously authorized days are not retroactively denied.
An expected length of stay is a planning benchmark, not a limit on covered days.

Denial Risk

Chronic Stable Dementia Without Acute Change

Admission for chronic stable dementia without an acute change from the documented baseline, or for behavioral symptoms of dementia alone, does not meet medical-necessity criteria under this policy.

These circumstances are not an acute medical condition and should be directed to appropriate behavioral, home, or long-term-care services.
Requests in these circumstances must be referred for physician review; they are not denied by an automated system or a non-physician reviewer.

Denial Risk

Awaiting Placement After Recovery

Continued stay after the underlying cause has resolved and the member has returned to baseline, solely while awaiting long-term-care placement, is custodial and does not support medical necessity.

Route the request to physician review and discharge planning.
Do not issue a retroactive denial for days that were already authorized.

Denial Risk

Routine Antipsychotic Administration

Continued stay solely for scheduled antipsychotic administration to treat delirium in a calm member is not supported. Routine antipsychotics are not recommended for delirium.

Note

Observation or Outpatient Management May Be Appropriate

Emergency-department care or observation, generally up to 24–48 hours, is the appropriate level when no inpatient admission criterion is met and the condition is expected to improve or can be managed safely outside the hospital.

AMS with a clear, rapidly reversible cause—such as corrected hypoglycemia, medication effect, mild dehydration, or an uncomplicated urinary infection treatable orally—with improvement toward baseline expected within 24–48 hours.
Mild delirium in a member with a reliable caregiver who can take oral fluids and medications and has outpatient follow-up arranged.
Chronic cognitive impairment without an acute change from the documented baseline.

Denial Risk

Unsupported Criteria or Excess Requested Services

Requests that fail the medical-necessity criteria, or that exceed the quantity, units, or duration supported by the documentation, must be referred for physician review. If only part of a request is supported, approve the supported portion and review only the unsupported excess.

Automated systems and non-physician reviewers may not issue an adverse determination.
Offer the requesting provider a peer-to-peer discussion before an adverse determination by a licensed physician of the same or similar specialty.
The absence of a criterion addressing a service is not, by itself, a basis for an adverse determination; apply generally accepted standards of medical practice.
Coverage remains subject to the member’s benefit plan and applicable federal and state law, including MHPAEA and 42 CFR Part 2 when applicable.

Expected length of stay

PurposePlanning benchmark for an uncomplicated course

Coverage limitationNot a limit on covered days

Use in planningHelps establish an expected course without restricting medically necessary covered days