Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a toddler who presented to the emergency department after having upper body shaking episodes, which lasted 2 to 3 minutes according to the patient's mother. The patient's mother reported no postictal stage, but the patient had frequent falls, was losing balance, and reported that symptoms began 4 to 5 months prior. The night before, the patient was in his mother's arms and began staring at the ceiling. The episode was described as non-focusing and the body was shaking for around 2 minutes. During the episode, the patient was rubbing hands together and zoning out. Afterwards, the patient cried "all night" and was unable to sleep. The report stated the patient was hospitalized previously because of rotavirus and dehydration. The diagnosis at the time of assessment in the emergency department was dehydration. The plan of care included neurology consultation given a concern for seizures. On assessment, the patient's lungs were clear to auscultation and his abdomen was soft and nontender. The patient ambulated normally and displayed no acute neurological deficits. The patient was tolerating oral feeds with no vomiting. There was a plan to admit for electroencephalogram (EEG) monitoring. The patient was subsequently admitted for further work-up with normal electrocardiogram (ECG). The laboratory report showed elevated platelet count at 402. The patient's mother claimed that the patient had issues with gait for 4 to 5 months, was often falling, and hitting head. The mother reported an incident of the patient falling recently while sitting on the couch with symptoms starting around the time the patient began walking without support. The mother denied gait issues with her other children. The patient was subsequently diagnosed with hyponatremia with sodium of 129 for which the toddler was placed on intravenous fluids. The toddler was also found to have positive rhinovirus and placed on continuous EEG monitoring with no episodes recorded. The patient was evaluated by physical and occupational therapy and recommended to have early dimension referral on an outpatient basis. X-rays of the lower extremities were performed given concerns for bowlegs. The patient was subsequently discharged in stable condition. 

According to the Milliman Care Guidelines, the patient was not a candidate for inpatient care. The patient presented with symptoms that indicated dehydration, which was addressed sufficiently in the emergency department with fluids. The patient was not febrile and had no other seizure-like episodes after treatment. The patient's mother claimed that the patient was having difficulty with frequent falls, losing balance for 4 to 5 months. Given the age, and reports of a lower extremity osteopathic condition termed bowlegged, this may have contributed to the issue and could have been addressed in an outpatient setting. In addition, the diagnosis of hyponatremia and rhinovirus did not require inpatient care as these conditions could also be addressed by the patient's primary care physician. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.