Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoplastic left heart syndrome
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a very complex medical history of palliated hypoplastic left heart syndrome who had been recently status post non-fenestrated extracardiac Fontan. He was readmitted for protein losing enteropathy (PLE), which is a very serious and possibly life threatening complication of the Fontan procedure. He was readmitted for a cardiac catheterization for a fenestration of his Fontan, which was complicated by thrombus in the fenestration, a common complication of PLE. Subsequently, he developed a large hemorrhagic stroke. He was treated for this as well as his PLE, when he was discharged home.
At issue is the medical necessity of an inpatient stay.

This child has serious, life threatening disease associated with his congenital heart disease. As part of his therapy, he required an interventional cardiac procedure that resulted in a stroke. All of these issues were medically necessary for an inpatient level of care.
This child was being treated for a stroke, protein losing enteropathy, and heart failure. He has serious, life threatening disease associated with his congenital heart disease. As part of his therapy, he required an interventional cardiac procedure that resulted in a stroke. All of these issues support the medical necessity for an inpatient level of care.
The patient was admitted the day before his catheterization to receive intravenous immunoglobulin (IVIG) due to his protein losing enteropathy.  He had the catheterization on day two, creating a Fontan fenestration, which was complicated by a thrombosis of the fenestration and requiring full heparinization.  On day three, as he was recuperating, he developed chest and abdominal pain and had a computed tomography (CT) of the abdomen/pelvis to rule out a retroperitoneal bleed.  Later that night, he developed seizure like movements, right sided hemiparesis, and aphasia and then became unresponsive.  A head CT scan that night showed a large intracranial hemorrhage.  He was sedated and monitored for seizures on continuous electroencephalogram (EEG) for the next few days.  His antiepileptic drug therapy was increased.  On day 7, he was stable enough for a brain magnetic resonance imaging (MRI) which confirmed the head CT findings.  He convalesced over the following days and his neurological symptoms and seizures improved.  A repeat head magnetic resonance imaging (MRI) scan on day 9 showed stability of the size of the hemorrhage and improved edema.  After discussion with the cardiac surgery, cardiology and neurosurgery team, he was discharged home.
This is a very medically complicated child with very complicated palliated congenital heart disease.  The child had failing Fontan physiology and protein losing enteropathy.  The plan for this admission was a fenestration of the Fontan to help some of these issues, but the hypercoagulable state led to complications in the catheterization lab with thrombosis of the fenestration and likely thrombosis to the brain.  When the patient was heparinized, this led to a hemorrhagic stroke.  The stroke was complicated by hemiplegia, aphasia, and frequent seizures.  This required intensive care as it could have developed into a neurosurgical case and required close follow up of this child's very tenuous hemodynamics.  There is no typical course for a patient as complicated as this, but the entire stay was appropriate, given the complexity of the issues.