Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal head movement and twitching. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

This case involves a child who presented to the hospital. The patient had a history of asthma. The patient presented with acute abnormal head movement and twitching after a cat scratch exposure from a stray cat that reportedly exhibited mouth froth. The patient was evaluated with unremarkable magnetic resonance imaging (MRI). Video electroencephalogram showed nonepileptic movement disorder. Laboratory results on the patient noted white blood cell (WBC) count of 5.6, red blood cell (RBC) count of 6.14, hemoglobin (Hgb) of 14.9, hematocrit (Hct) of 44.8, potassium of 4.0, sodium of 141, blood urea nitrogen (BUN) of 11, creatinine of 0.72, and glucose level of 88. The urine drug test was negative. The physical exam noted no focal neurological deficits. There was no change in the patient's behavior. The patient reported right-sided neck pain with stiffness. The patient continued with jerky head movement with eye twitching and occasional leg twitching in the emergency department. The patient was admitted for evaluation of abnormal head and limb movements. The patient reported history of fever of 101.1 degrees Fahrenheit when at home 3 days prior. This was associated with diarrhea and vomiting.  There was a family history of seizures and multiple sclerosis.  The patient was treated for yeast infection with Diflucan and a dose of Benadryl for vaginal pruritis. The patient received 1 rabies vaccine with subsequent vaccine scheduled in the upcoming weeks.  The patient started on antibiotic course of amoxicillin. Discharge diagnoses included nonepileptic movement disorder and rabies exposure. 
It was stated that the inpatient hospital admission from was not medically necessary. The patient was not unstable, the patient did not have seizures due to fever, there was no recurrent or continuous seizures, there was no altered mental status, and there were no severe brain findings. 
Per the cited references, admission to the hospital is indicated for pediatric patients suspected of seizure when there is hemodynamic instability, when there is febrile seizure, when there is suspicion for meningitis, for status epilepticus, for brain disorder that requires monitoring or intervention available only at inpatient level of care, for etiology that requires monitoring or intervention available only at inpatient level of care where that persist despite observation care, for altered mental status that is severe persistent, for new focal neurological deficits, and for recurrent seizures. In this case, the patient presented to the hospital with abnormal head movement and twitching. It was argued that the inpatient hospital admission was medically necessary. The patient was tachycardic with a heart rate of 120. Upon serial monitoring, the patient continued to have twitching which was consistent with failure to achieve symptom improvement. This necessitated acute inpatient care. However, based on the findings, the patient's evaluation could have been completed at observation level of care. There was no hemodynamic instability, febrile seizure, suspicion for meningitis, a brain disorder that required monitoring or intervention only available at inpatient level, altered mental status, focal neurological deficits, or recurrent seizures. 
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 inpatient hospital admission is not substantiated.