Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diagnosis: Loss of consciousness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with sickle cell disease. She was admitted for evaluation of a spell of loss of consciousness. She was going to the bathroom when she became wobbly. Her mother held her before she fell. She retained consciousness with responsiveness for approximately one minute. She was taken to the ER (emergency room) by her parents. In the ER (emergency room), she reported abdominal pain.

The patient's general and neurological exams were normal. While in the ER (emergency room) she developed a temperature of 103 degrees Fahrenheit. An EKG (electrocardiogram) was normal. A chest X-ray showed an enlarged cardiac silhouette without pulmonary disease. A KUB (kidney, ureter, bladder) X-ray showed significant retained stool. She tested positive for COVID. Her hemoglobin was 8.2.

During admission, the patient's history included non-compliance with hydroxyurea. She had completed transcranial doppler studies earlier in the year. Neuro checks were ordered every 3 hours. The neurology team was consulted and recommended outpatient follow up, as MRI (magnetic resonance imaging) and EEG (electroencephalogram) could not be completed due to her COVID positive status.

Per the notes, the differential diagnosis included viral syndrome vs syncope vs transient ischemic attack. The patient was treated with Lovenox during the admission. She was discharged home with instructions to follow up with the neurology team.

Coverage for the admission was denied by the health plan as not medically necessary due to not meeting Interqual acute pediatric admission criteria. The denial was appealed with the argument that the patient required care only available at the inpatient level due to the high risk of complications from sickle cell disease and that she met several Milliman inpatient level care criteria. The review is in regards to the medical necessity of the inpatient admission.

No, the Inpatient admission was not medically necessary.
The patient had a syncopal/near syncopal event in the setting of a COVID infection and her history of sickle cell disease. By the time of admission, the patient was neurologically stable with a normal neurological exam. There was a desire to perform further neurological testing with MRI (magnetic resonance imaging) and EEG (electroencephalogram), however, these were deferred due to her COVID positive status. There were no focal neurological deficits, prolonged alternation of awareness, prolonged post-ictal state, or other sickle cell complications such as sickle cell crisis, acute chest syndrome, splenic sequestration or signs of central nervous system infection.

The patient's care included monitoring and treatment with Lovenox along with neuro checks. The patient did not require advanced neuroimaging, transfusion or exchange transfusion, or correction of severe metabolic disturbances via IV (intravenous) fluids. Though the differential diagnosis of transient ischemic attack or seizure was considered, there was no further evaluation performed for evaluation of these disorders and thus could have also been managed in observation stay.

Thus, the acuity of the patient's condition and the type of testing and care did not require inpatient level admission. The care provided could have been provided at an observation level. If there were complications or new serious diagnoses made during the care, the status could have been changed to acute inpatient admission at that time.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As discussed above, the patient did not require acute inpatient level care. The patient had a syncopal event and was COVID positive. The level of care provided could have been accomplished in an observation level of care. If there were complications or other serious etiologies for her symptoms found, the level of care could have been changed to inpatient level at that time. Thus, the plan did act reasonably, with sound medical judgment and in the best interest of the patient, as acute inpatient level care was not required.