Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for cocaine abuse, alcoholism, tobacco use, alcoholic pancreatitis, hypertension, anxiety, microscopic anemia, and a stroke with a residual speech deficit who presented to the emergency department with complaints of a generalized headache that was described as constant. The headache started one day before the presentation. The associated symptoms included nausea. The patient vomited once. The headache was described as pressure-like. The patient reported having had a similar headache in the past. The review of systems was negative for vision changes, unilateral weakness, paresthesias, seizures, bowel or bladder incontinence. Reportedly, the patient tried to take Fioricet at home but it did not help.
When the patient was seen by the admitting physician she was afebrile, her heart rate was 70 beats per minute, respiratory rate 16 breaths/minute, blood pressure 159/81, and oxygen saturation 98% on room air.
The patient was in no acute distress and the head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi.
The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The patient had a cast on the right wrist.
On the neurologic exam, the patient was lethargic but easily arousable and there were no focal deficits. Muscle strength and sensation were intact. There was a right facial droop and slurred speech. It was mentioned that the slurred speech was chronic and related to the previous stroke.
A computed tomography (CT) scan of the head without contrast showed no acute changes. The patient had chronic changes with a broad differential diagnosis.
The patient was admitted to the hospital with a frontal headache and slurred speech. The admitting physician indicated that the patient had slurred speech at the baseline. A neurologic consultation was requested. The other admitting diagnoses included anemia that was stable, mild hypokalemia that was corrected, hypertension, alcoholism, and cocaine abuse. The patient was evaluated by a neurologist who suspected that the patient had rebound headaches versus migraines, which were exacerbated by cocaine use. The neurologist stated that the patient underwent  magnetic resonance imaging (MRI) of the brain that showed no stroke. The neurologist recommended treatment with Topamax, cessation of cocaine use, and outpatient follow-up with a neurologist.
During the hospital stay, the patient continued to remain in stable clinical condition, therefore she was discharged from the hospital. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records demonstrated that the patient had no severe or persistent altered mental status, severe or persistent vomiting, severe or persistent dehydration. The imaging studies did not demonstrate that the headache was associated with unruptured but symptomatic aneurysm of vascular malformations, venous sinus thrombosis, increased intracranial pressure, cerebral spinal fluid leak. The review of the medical records did not reveal any suspicions the patient had a medication overdose induced headache, vasculitis. In the hospital, the patient was examined by a neurologist who did not indicate the presence of papilledema, cerebral edema, mass effect on CT scan, cerebral bleeding, ischemia, hydrocephalus, or uncontrolled seizures. There was no mention that the patient had focal neurologic signs, except for the chronic neurologic symptoms related to a previous stroke. She underwent an occipital nerve block. The patient tolerated the procedure without complications. An occipital nerve block is a procedure that involves injecting pain-relieving medication and steroids into the greater and lesser occipital nerves. Some of the specific conditions it is commonly used to treat include the following: migraines, cluster headaches, spondylosis of the cervical facet joints, occipital neuralgia. In general, this procedure does not require admission at the acute inpatient level of care. Taking into consideration all of this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.