Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Other-Gastrostomy Tube Placement
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has overturned in whole the health plan determination.

This pediatric patient has a medically complex history including neurologic impairment and required feeding access. He underwent a laparoscopic gastrostomy tube(GT) placement, and the course was complicated by possible seizures, emesis, as well as an elevated Pediatric Early Warning Score(PEWS).
The requested service is medically necessary, and it requires an inpatient admission. This is a medically complex, neurologically disabled patient who required enteral access to provide feeding. This child had an elevated heart rate on admission and seizure like activity. His hospital stay included evaluation and treatment for this as well as placement of a gastrostomy tube. His electroencephalogram (EEG) did not capture the seizures, however, showed poor organization, slowing frequency when awake and faster frequency at sleep along with sharp waves. All of this is abnormal and a child with this type of EEG pattern can be at risk for not protecting their airway during GT feeds- which can lead to aspiration and death. Therefore, inpatient admission is required as feeds are advanced. Per nursing note, his PEWS(3) was yellow- this means that his scores on vital signs were abnormal necessitating evaluation by a physician. After introducing bolus feeds, he had emesis- so feeds needed to be withheld and then restarted. GT placement in children typically occurs due to severe underlying disease- this is not able to be done in an outpatient or ambulatory setting. This patient demonstrated several physiologic signs that were not safe for discharge. Emesis in a neurologically impaired child is a dangerous occurrence as they cannot protect their airway and can aspirate and die. Surgery in neurologically impaired children can lower the seizure threshold and this is imperative to address.
The article published in 2020 on implementation of a care bundle for gastrostomy tube placement in children reports that the median length of stay (LOS) after the bundle was implemented was 7 days.
"Median LOS was reduced from 15.3 to 7.1 days" In a medically complex patient, 7 days would be a minimum length of stay. The services provided to this child also require skilled nursing- not things that a (lower level) status could provide. A neurologically impaired child that receives a GT can suffer from aspiration. In reference 2 and 4, it states: "Disordered swallowing in children with neurological impairments may be associated with clinically significant undernutrition and aspiration, culminating in respiratory compromise, poor health, and sometimes, early mortality." With bolus feeds, reflux can occur, and the patient would not be able to protect the airway. A Pediatric Early Warning Score can potentially predict clinical deterioration in a child. In reference 3, they found that "PEWS can potentially provide a forewarning time >11 hours, alerting the team to adapt the care plan and possibly averting a Rapid Response Team or code."