Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Cough 
Treatment Inpatient Admission: Intensive Care/Other Sub-Acute Care 

The insurer denied Inpatient Admission: Intensive Care/Other Sub-Acute Care. 
The determination is overturned. 

The patient has a complex medical history significant for drug rash with eosinophilia and systemic symptoms (DRESS) syndrome secondary to anticonvulsant medications, intractable epilepsy status post two separate resections of the left occipital lobe with aspiration pneumonia complicating the second surgery, exotropia, bilateral rectus muscle recession with visual field cut, hypercalciuria with nephrolithiasis, hypocitraturia, ataxia, apraxia, hypotonia, hemiparesis, scoliosis, persistent tachycardia, and global developmental delay. He remains on anti-epileptic medications and ketogenic diet to control his seizures. Triple endoscopy was scheduled because of 6-month history of chronic cough and negative modified barium swallow study. 

He presented to ambulatory surgery for direct laryngoscopy, rigid bronchoscopy, and upper endoscopy under general anesthesia. Findings included interarytenoid edema with a laryngeal cleft extending to the vocal process, prolapsed epiglottis, and normal tracheobronchial tree anatomy (bronchoalveolar lavage specimens sent for analysis, positive for lipid laden macrophages). Biopsies were taken of the stomach and duodenum, ultimately unremarkable. He received a dose of Valium post-operatively for seizure prevention. He recovered uneventfully in the post-anesthesia care unit (PACU) and was transferred to the pediatric floor for overnight admission due to a complex and complicated seizure history, perioperative treatment with corticosteroids that might affect ketosis, and recurrent aspiration pneumonia. Admission orders included continuation of home anticonvulsant medications, rectal Valium for prolonged seizure, continuation of other home medications, and 3:1 ketogenic diet. He did well, with no breakthrough seizures or other medical issues, and was discharged home the following day. At issue is the medical necessity of inpatient hospital admission: Intensive Care/Other Sub-Acute Care. 

This patient has a number of complex medical issues, including refractory seizure disorder status post two sequential seizure surgeries and treatment with ketogenic diet, that were under treatment at the time of his triple scope (direct laryngoscopy, rigid bronchoscopy with bronchoalveolar lavage, and upper endoscopy with esophagus and stomach biopsies). Surgery while in ketosis is associated with potential risks such as metabolic acidosis and increased seizures. In addition, there is concern that treatment with steroids may affect ketosis, and in a patient such as this child might precipitate seizure. Based on this child's clinical history and the complexity of his medical problems, it was reasonable and appropriate to admit following outpatient triple scope under general anesthesia to monitor return to his ketogenic diet and resume his routine anticonvulsant medications. It is not unusual to monitor children overnight after procedures requiring anesthesia in the context of complex clinical history and/or difficult to manage medical problems. Such was the case with this child. His seizure disorder is extremely complicated and difficult to manage, requiring two brain resection surgeries, multiple medications, and ketogenic diet. His procedure was done under general anesthesia, which would require a period of nothing by mouth, as well as changes in his medication schedule. Because of his clinical complexity, recovery time could also be affected (eg prolonged). Recovery room staff are not equipped to manage the potential complications that could arise, such as prolonged seizure, or delayed recovery. While this child did not experience any complications from his period of fasting and was able to resume his medications without too much delay, that would not have been known at the time of the procedures. Safety and standard of care dictated an overnight stay in the hospital for close monitoring and return to baseline.  This is consistent with the current standard of care and evidence-based treatment guidelines.