Appeal type: Medical necessity
Decision: Overturned

Other
Inpatient Hospital

This is a patient who presented with complaints of worsening ptosis of both eyelids for the last day or so. He also had slurred speech and dizziness that was noted on the day of presentation. He had been seen in the past for ptosis that developed slowly over the last several weeks. He had been seen by ophthalmology as well as neurology in the past. He recently had a magnetic resonance imaging (MRI) scan of his brain as well as lab work done that had apparently been unremarkable. He was recently started on prednisone by neurology as well. Speech difficulty and dizziness were new complaints on the day of presentation.
On examination he had some slurred speech and slight deviation of his tongue to the left. He also had positive Babinski signs. It is noted that documentation was reviewed that was faxed over from his doctor showing the normal MRI with and without contrast as well as normal lab work. The MRI was limited by his braces. Given his extensive recent work up, no additional blood work was done. Pediatric neurology was contacted for consultation. They evaluated him in the emergency room and they requested admission for further diagnostic work up of abnormal neurological findings. At the time of admission, it is reported he had no other signs of impending respiratory or neuromuscular disease with impending muscular compromise.
Neuro checks were ordered every four (Q4) hours as well as a lumbar puncture and possible repeat MRI as the first one was limited by braces. In the emergency room (ER) a neurologist did note some abnormalities to the eyes with possible cranial nerve palsy and some disconjugate movements of his left eye. He also mentioned that the right pupil was bigger than the left and both were reactive. His list of findings stated child with diffuse hyperreflexia, bilateral asymmetric ptosis, ophthalmoparesis, dysarthria with a possible right sided tongue weakness and a rash which looked like multiple excoriations. While in-house, plastic surgery was called to perform a punch biopsy of skin lesions as he had a rash concerning for a vasculitis. Lumbar puncture was also performed. Throughout the hospitalization, the patient was monitored closely for progressing symptoms. He reportedly had worsening of his dysarthria. A lumbar puncture was done and MRI of his brain as well as entire spine was done which returned normal. He was found to have brisk reflexes and electromyography (EMG) was performed. He was treated with empiric intravenous immunoglobulin (IVIG) due to the suspicion of a possible autoimmune cause for symptoms. On the third day of admission, the patient had acute worsening of his headache and vomiting. This was treated as a rapid response and Neurology came to the bedside to assess immediately. The pain was improved by placing the patient flat in bed and they suspected he was having lumbar puncture headache. He had a computed tomography (CT) scan of the chest abdomen and pelvis which showed residual thymus and mesenteric adenitis. The EMG was normal with no evidence of myasthenia or Guillen Barre. The patient's symptoms eventually showed some improvement and he was cleared for discharge home. At the time of discharge, the patient was instructed to follow up with his primary medical doctor (PMD), neurologist, and rheumatologist.
The health plan's determination is overturned.
This patient presented with progressive neurological symptoms. As Guillain-Barre was a diagnostic consideration at the time of admission, close monitoring for progression and possible respiratory failure would be necessary at inpatient level of care. The diagnostic and treatment plans for his complex and progressive complaints required inpatient level of care as he received IVIG as well as high dose steroids. These treatments require close monitoring of vital signs and attention to possible adverse events. The Milliman Care Guidelines (MCG) Health Neurology GRG document inpatient level of care for vasculitis (which was suspected by medical team and was evaluated with biopsy done while admitted) as well as for new onset neurological findings which require inpatient care such as Guillain-Barre syndrome. For these reasons, the patient required an inpatient level of care to appropriately and safely care for him.