Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic autoimmune encephalitis, anxiety disorder, and non-epileptic seizures
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient was a teenage female with chronic autoimmune encephalitis, anxiety disorder, and non-epileptic seizures. She was admitted for an inpatient hospital stay. She developed worsening agitation and combative behavior. Her treatment course included intravenous immunoglobulin (IVIG), steroids, and rituximab. These treatments were stopped by one of her treatment teams a few months earlier. Her behavior worsened with the development of agitation and she was taken to the emergency department. Her history included multiple emergency room and hospital stays. Her home medications include Zyprexa, Zoloft, Ativan and Thorazine. While in the Emergency department, the patient received Thorazine, Benadryl and lorazepam due to agitation. Her vital signs showed tachycardia and mildly elevated blood pressure. Pertinent labs included a white blood cell count of 13.4 thousand. She was admitted. 

During the admission, the patient had psychiatry and neurology consultations. The consulting psychiatrist gave recommendations to continue her home medications and instructions for medications to be used for intermittent agitation. The psychiatrist stated in the note that the patient did not need inpatient psychiatric admission. The neurological history found that the patient had previously undergone extensive testing last year and the findings were consistent with autoimmune encephalitis. The patient improved after receiving Rituximab, but her status worsened after they were discontinued. The consulting neurologist wrote a handwritten note stating an impression that the patient had "rule out flare up of autoimmune encephalitis". The recommendation was to keep her safe and sedated overnight and to transfer to another hospital the following day. The admitting physician discussed with her neurologist at another institution who recommended re-evaluation. The plan was developed to transfer her to another children's hospital for further care which included potential evaluation with neuroimaging and lumbar puncture. The patient remained admitted overnight. This review is in regard to the inpatient hospital admission.

The proposed inpatient hospital admission was medically necessary.

Patients with acute relapse of autoimmune encephalitis require prompt evaluation and management (Reddy, Zuliani). This often requires inpatient level care depending on the symptoms the patient exhibits. In this case, the patient had acute worsening of combative and agitated symptoms and required sedatives in the emergency room and on the hospital floor. Her history showed that she had been diagnosed with autoimmune encephalitis, and the concern was that she had relapsed because she had been without immunomodulatory treatment. Thus in this case, there was a concern that the patient had an active and acute decline in neurological functioning as exhibited by her behavior. While admitted, the patient was not completely stabilized because she required repeat dosing of the daily medication's to keep her calm. The patient required ongoing monitoring for worsening of her agitated combative symptoms, which posed a major threat to her and others' well-being. 

As the patient had suspicion of worsening of autoimmune encephalitis, she required prompt care. During the time the patient was admitted, it was determined that the patient needed a higher level of care. Though all the care did not occur at the facility in question, her stay there is seen as part of the continuum of her care. While admitted at the facility in question, the patient could not be deemed safe for discharge home and required ongoing management with as needed psychiatric medications. Thus, the acuity of the care required acute inpatient level care.