Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned
 

Emergency department note reported the patient was transferred from another facility for arthralgia, tingling/numbness in the upper and lower extremities, shortness of breath, jaundice, abdominal pain, nausea, and vomiting for the last week prior to admission as well as weight loss and generalized body weakness.  The patient also described facial numbness on the right side with blurry vision.  Past medical history was significant for lupus, hypertension, hypothyroidism, alcohol use disorder, untreated Lyme disease, Bell's palsy, fecal incontinence, and urinary incontinence.  It was noted that the patient has been using a wheelchair for approximately two years.  The patient also had a history of admission for lower extremity weakness, urinary incontinence, bowel incontinence, and left knee pain.  It was noted that because of symptoms not being clear, differential diagnoses included conversion disorder and malingering for secondary gain.  The patient also had a history of admission for similar presentation.  Exam noted tachycardia with motor weakness.  Assessment was generalized weakness.  Plan was for labs.  Electrocardiogram (EKG) noted QTC prolongation.  Labs noted elevated liver function test and low Hemoglobin and Hematocrit (H&H).  The provider noted there was mixed hyperbilirubinemia.  The patient was recommended for admission.  Neurology consultation reported examination was more consistent with severe polyneuropathy.  Treatment plan was for lumbar puncture and magnetic resonance imaging (MRIs) as well as labs.  Gastroenterology consult reported the patient may benefit from esophagogastroduodenoscopy (EGD) prior to discharge pending work-up for inability to ambulate.  Endocrinology consultation reported the patient had abnormal thyroid function tests (TFTs) and was recommended for labs as well as follow-up in 4 weeks.  Rheumatology consultation reported the patient had extensive work-up in the past for autoimmune disorder.  The patient was not taking any medications for lupus.  Treatment plan included prednisone, lumbar puncture, MRIs, and labs for lupus flare work-up.  Progress note reported MRI was unremarkable for inflammatory process.  The patient refused to have lumbar puncture completed.  Radiographs of the knee noted soft tissue swelling with no effusion.  Treatment plan was to continue with prednisone.  EGD completed noted esophageal exudates, gastritis, duodenitis, and gastric nodule.  Discharge summary reported the patient was discharged to short-term rehab with follow-up with rheumatology and neurology as outpatient.  

The patient met Milliman Care Guidelines (MCG) clinical indications for admission to inpatient care given neurologic finding requiring inpatient care as evidenced by weakness that was progressive or severe (e.g., inpatient care needed due to functional disability, concern for safety). The patient also had tingling/numbness in the upper and lower extremities, shortness of breath, jaundice, abdominal pain, nausea, vomiting, weight loss, and generalized body weakness.  The patient also described facial numbness on the right side with blurry vision.  Labs noted elevated liver function test and low H&H.  The provider noted there was mixed hyperbilirubinemia.  The patient was recommended for admission.  The patient underwent additional testing to include labs and imaging. Multiple consultations were ordered. Inpatient care was supported given the severity of symptoms and extensive work-up required.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.