Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Encephalopathy
Treatment: Inpatient Hospital Services
The insurer denied the inpatient hospital services.
The denial is overturned.

The patient is a male who presented to the emergency department with worsening dizziness, weakness, vomiting, and confusion. Pertinent history included positive coronavirus 2019 (COVID-19) test. Additional history included a prior cerebrovascular accident (CVA) with residual left-sided weakness and seizure disorder. Initial vital signs revealed a temperature of 97.8 degrees Fahrenheit (F), heart rate (HR) 68, blood pressure (BP) 115/81, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 100% (percent) on room air.

Computed tomography (CT) of the head revealed a hypodensity in the right frontoparietal centrum semiovale and corona radiata. CT angiogram revealed an unchanged large arteriovenous malformation comprising of the majority of the right cerebral hemisphere. The patient was admitted. The admitting physician documented the patient was confused and yelling incoherently. The initial impression was altered mental status and COVID-19 infection without hypoxia. Treatment plan included intravenous fluids, additional laboratory testing, magnetic resonance imaging (MRI) brain, and consultations. Neurology consultation was obtained who noted the patient yelled to noxious stimuli, but otherwise was nonverbal. Recommendations were to continue anti-epileptic drugs and obtain an MRI Brain/electroencephalogram (EEG). If no improvement in mental status, a lumbar puncture was to be pursued.

EEG revealed slowing of the right greater than left hemisphere without epileptiform activity. The patient was noted as awake, alert, but disoriented to time or situation. The translator did note the patient was mumbling at times and unsure why he was in the hospital. Hemodynamics were stable. Right upper quadrant (RUQ) ultrasound was relatively unremarkable. No significant change in treatment. It was noted that the patient's mentation had significantly improved and was almost at baseline. The patient was discharged.

Based on the clinical documentation provided, evidence based literature and standards of care, inpatient hospital services was indicated as medically necessary for the entire admission.

Pinson notes acute encephalopathy is characterized by an acute or subacute global, functional alteration of mental status due to systemic factors. It is reversible when these abnormalities are corrected, with a return to baseline mental status. Acute encephalopathy may be further identified as toxic, metabolic, or toxic-metabolic. Toxic encephalopathy describes acute mental status alteration due to medications, illicit drugs, or toxic chemicals. Metabolic encephalopathy is caused by any of a large number of metabolic disturbances. Toxic-metabolic encephalopathy describes a combination of toxic and metabolic factors. Causes of acute toxic and metabolic encephalopathy include acute organ failure such as hepatic and renal, alcohol, dehydration, electrolyte imbalance, fever, hypertension, hypoxemia, illicit drugs, infections including sepsis, medications, toxic chemicals, and Wernicke (thiamine deficiency). [1] Dobbs notes acute toxic encephalopathies exhibit symptoms and signs along a spectrum that includes mild confusion, attention deficits, seizures, and coma. Central nervous system (CNS) capillary damage, hypoxia, and cerebral edema play major roles. Depending on the toxin, the dose, and the individual, neurologic symptoms may resolve with removal from exposure.[2]