Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Guillain-Barre syndrome

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is overturned

The patient presented to the emergency department reporting weakness and lower extremity numbness. Records stated that she was previously admitted to the hospital for COVID-19, anemia, and pulmonary embolism.  The patient was admitted due to concerns for Guillain-Barre syndrome for further evaluation, treatment, and monitoring. The emergency provider note stated that the patient was admitted and discharged earlier in the week for fatigue after having been found with a hemoglobin (Hgb) of 5. She was given a blood transfusion and was subsequently diagnosed with pulmonary embolism and started on Eliquis. Since starting the treatment, she endorsed intermittent lower extremity cramping and numbness, but denied chest pain, shortness of breath, nausea/vomiting, or abdominal pain. Her physical examination was negative for any neurological abnormalities. The consultation report stated that computed tomography (CT) of the head was unremarkable with no back pain and no bladder or bowel dysfunction. Her examination was positive for +4/5 upper extremity strength and proximal distal lower extremity strength graded 4/5. Reflexes were absent with toes downgoing, sensation was grossly intact, and she was currently ambulating with a walker. Per the patient's daughter, the patient was getting progressively weak in the legs with associated numbness. Magnetic resonance imaging (MRI) of the brain noted asymmetric prominence of the right pituitary gland measuring 8mm (millimeters), with an underlying pituitary lesion suspected. The patient was subsequently admitted for further evaluation, treatment, and monitoring. This review pertains to the inpatient admission.  

Literature states that neuromuscular emergencies may be defined as disorders or exacerbation of diseases of the peripheral nervous system and a rapidly progressive and potentially life-threatening. Such disorders can affect a little of the peripheral nervous system, from a muscle to the anterior horn cell. Some disorders, such as Guillain-Barre syndrome, provide the additional threat of severe, and potentially irreversible nerve loss. The Milliman Care Guidelines have stated that a clinical indication for admission to inpatient care includes patients who have neurological findings requiring inpatient treatment such as with weakness that is progressive or severe, new onset of paralysis, with progressive or severe symptoms, as well as those patients suspected of having Guillain-Barre syndrome.  

Based upon the provided information, it was determined that in taking the age of the patient into consideration, her recent bout of COVID, anemia, and pulmonary embolism, admission for further work-up, care, and monitoring was reasonable given that her symptoms were not improving, but were progressing, and may have been due to an unknown cause that could potentially lead to other symptoms. Based upon the provided information, the patient met the criteria for an inpatient level of care to address her condition.  

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.