Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history significant for attention deficit hyperactivity disorder (ADHD) inattentive type, tic disorder, recent coronavirus 2019 (COVID 19) infection the month prior, and acute gastroenteritis a month prior, who presented to the ED with excessive clumsiness and bilateral leg weakness. She had fallen multiple times over the previous couple of days, and on the day of presentation experienced some dizziness and had a brief loss of consciousness but no loss of bowel or bladder control. In the ED, the evaluation was unremarkable, including a negative head computed tomography (CT) scan. On the pediatric floor, the vital signs included a temperature of 36.9 degrees Celsius, heart rate 96, respiratory rate 20, and blood pressure 98/72. The examination was significant for mild bilateral nystagmus, hypoactive reflexes, decreased power, bilateral extremity weakness. Laboratory evaluation was relatively unremarkable. Magnetic resonance imaging (MRI) of the spine was unremarkable, no significant abnormality.
Admission orders included continuous telemetry, possible lumbar puncture, neurology consultation, regular diet, continuous cardiac monitoring, and possibly cardiology consultation. During her hospitalization, she recovered her strength and balance. She was evaluated by psychiatry (no acute inpatient needs), neurology (recommended outpatient electromyography (EMG) / nerve conduction velocity (NCV)), and cardiology (follow-up electrocardiogram (EKG) and benign murmur in the outpatient setting. She was ambulating independently, neurologic exam within normal limits, and was deemed stable for discharge.
At issue is the medical necessity of an inpatient stay.
The requested inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care, including all consultations.
Guillain-Barre syndrome is an immune-mediated disease typically triggered by infectious diseases. The clinical presentation is variable making diagnosis sometimes challenging. Patients typically report an ascending weakness and sensory deficit, beginning in the legs and progressing up to the arms and cranial muscles. Diagnosis is based on history, neurological exam, cerebrospinal fluid (CSF) findings, and electrophysiologic data. Peak disability typically occurs in two weeks. About 20% go on to develop respiratory failure and require intubation with mechanical ventilation. Cardiac arrhythmias may occur if the autonomic nervous system is involved. Treatment may involve intravenous immunoglobulin (IVIG) or plasma exchange.
This female presented to the ED with a various constellation of complaints, most prominently lower extremity weakness with a history of recent viral infection. There was initial concern about Guillain-Barre syndrome so she was admitted for monitoring. She was evaluated by a number of subspecialists during her hospitals stay, with no definitive answer found for her lower extremity weakness. While it was not unreasonable to monitor her for progression or regression of symptoms, she was overall hemodynamically stable with no evidence of impending respiratory failure and no reported suicidal ideation. She did not require acute inpatient admission and could have been safely managed at a lower level of care.