202102-134924
2021
Metroplus Health Plan
HMO
Genetic Diseases, Central Nervous System/ Neuromuscular Disorder
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Dandy-Walker syndrome, developmental delay,
ventricular shunt, mental retardation, and seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
This male has conditions including Dandy-Walker syndrome, developmental delay, ventricular shunt, mental retardation, and seizures. The patient presented with his mother to the emergency department (ED) because the mother was unable to care for him after breaking her leg. He had no medical complaints.
The patient's vital signs (VS) were as follows: temperature 97.7, pulse 93, respiratory rate 18, nlood pressure 124/71. and oxygen saturation 97%. Exam was remarkable for nonverbal and does not follow commands. Complete blood count (CBC) was unremarkable. Comprehensive metabolic panel (CMP) was remarkable for sodium (Na) 147 and aspartae aminotransferase (AST) 16. The patient was admitted for social disposition. The maximum temperature (Tmax) was 101.5, there was no acute disease (NAD), and no leukocytosis. Plan was for blood cultures. Antibiotics were put on hold.
No, the proposed treatment was not medically necessary.
Medically necessary services are those which are:
safe
effective
generally accepted national standard of medical practice
not provided primarily for convenience of the patient or the practitioner
the least intensive and/or most appropriate alternatives among diagnostic and treatment option.
The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.
Vital signs were stable (VSS); the patient was afebrile. Chest x-ray (CXR) showed no acute disease (NAD). Blood cultures were negative. Urine analysis (U/A) was negative. Coronavirus (COVID) was negative. The patient remained hemodynamically stable and afebrile though hospital stay. Discharge was delayed pending discharge planning. The patient was discharged.
This is a patient with chronic conditions including Dandy-Walker syndrome, developmental delay, and mental retardation. The patient was admitted for social disposition after his mother was unable to care for him. He was hemodynamically stable and in no acute distress. Labs were unremarkable for acute findings that required an inpatient level of care. There were no acute conditions identified. Plan of care was placement. The patient had one time temperature spike with negative work up. Otherwise, his hospital stay was unremarkable. He was not receiving interventions at an acute inpatient level of care. Discharge was delayed pending placement. He was discharged after being placed in a nursing home. Inpatient admission was not medically necessary for this scenario.