Appeal type: Medical necessity
Decision: Overturned

This is a patient with a complicated medical history significant spina bifida with myelomeningocele status post correction with extensive reconstructive surgery, congenital hydrocephalus status post ventriculoatrial (VA) shunt with a history of multiple shunt malfunctions, neurogenic bladder status post nephrostomy with Mitrofanoff creation with last revision in 2018, asthma, myelodysplasia with severe scoliosis and restrictive lung disease, paraplegia, hypertension, gastroesophageal reflux disease, and history of deep vein thrombosis status post course of Lovenox. She presented to the emergency department (ED) with a one-week history of right ear pain and pressure and two-day history of nausea and vomiting. She denied fevers. Vital signs included temperature 36.6 degrees Centigrade, heart rate 94, respiratory rate 16, and blood pressure 134/82. Pain was rated 6/10.
Examination was significant for some mild edema of the right ear canal with no pain with movement of the external pinna, no meningismus, shunt palpable at the right neck, wheelchair-bound, and well-appearing. Rapid strep testing was negative. A urinalysis was significant for nitrites and large leukocyte esterase consistent with urinary tract infection; urine culture was sent. A shunt series was normal. A viral panel was obtained, with pending results in the emergency department (ED). She was treated with Tylenol with resolution of her headache. A neurosurgery consultation was sought, with recommendations for a full infectious work-up, magnetic resonance imaging (MRI) scan versus computed tomography (CT) scan, and shunt series. Despite the Radiology interpretation of a stable head CT, the neurosurgeon noted a slight increase in ventricular size compared to previous, prompting recommendations to monitor in the Pediatric Intensive Care Unit (PICU) for 24 hours, as well as nothing by mouth after midnight in case she required surgical intervention. Admission orders included hourly neurologic checks, continuation of home medications, and nothing by mouth pending operating room (OR). A viral panel returned positive for human metapneumovirus. She remained neurologically stable overnight. Ear, nose, and throat (ENT) was consulted for ear pain, with identification of temporomandibular joint (TMJ) dysfunction/pain. Recommendations included warm compresses, massage, and nonsteroidal anti-inflammatory drugs (NSAIDs) . A urine culture remained negative, so no antibiotics were prescribed. The health plan's determination is overturned. This young patient with a complex medical history including multiple episodes of shunt malfunction necessitating revision presented to the ED with prolonged ear pain and a two-day history of nausea and vomiting. Neurosurgery was concerned for slight ventricular enlargement on head CT. She was admitted for frequent neurologic checks (every hour) and consideration for surgical intervention. Upon clearance from Neurosurgery, ENT was consulted, diagnosing TMJ pain. Her hospital stay was further complicated by a urinalysis suspicious for infection (with leukocyte esterase and nitrites) and viral panel positive for human metapneumovirus. Her headache resolved with analgesia, the urine culture was negative, and she remained stable on room air with no need for additional bronchodilators. While resolution to her presenting signs/symptoms/ailments happened within 24 hours, with no need for neurosurgical intervention or ENT intervention, the care that she received (including hourly neurologic checks, medication administration, diagnostic testing) was most consistent with acute inpatient management. She could not have been safely managed in the outpatient setting, and the complexity of her case was not appropriate for a lower level of care. The acute inpatient stay was medically necessary and appropriate.