Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This case involves an adult who presented to the emergency department (ED) complaining of dizziness, generalized weakness, and headaches for 3 days.  On initial assessment, the patient's heart rate was elevated at 106 and the remainder of her vital signs were stable.  She was obese with a body mass index (BMI) of 30 and rated her pain 4/10 at rest and with activity.  The patient had an episode of unresponsiveness for 5 minutes while in the middle of assessment and while talking with the physician and the examining nurse.  The document noted the patient was Spanish-speaking and displayed no signs or symptoms of alcohol intoxication.  Records claimed that when the patient arrived to the ED, she was able to answer all questions appropriately but when assessed by a translator, she stared into space and did not answer any questions.  Within less than 1 minute, the patient seemed to have fallen asleep.  The patient had no history of seizures and had no documented hand tremors or tongue fasciculations on reassessment.  Records claimed that she had a history of brain aneurysm but no bleeding on computed tomography (CT) with plans to order a CT angiography.  The clinical summary stated the patient was tachycardic with acute mental status changes. 
The plan was to do a sepsis work-up and hold off on any antibiotics.  A straight catheter would be used to obtain urine and there were plans to admit the patient.  

The history and physical report stated the patient had a history of hyperlipidemia, fibromyalgia, insomnia, and anxiety.  She reported a fall suffering a head laceration.  She reported more frequent panic attacks associated with shortness of breath, palpitations, diaphoresis, and nausea and was unable to sleep and felt dizzy when walking.  Laboratory values noted that the patient's serum glucose was elevated at 124.  Additional findings included low serum acetaminophen level of less than 2 and low serum salicylate level at less than 1.7.  A CT of the head without contrast showed no mass effect, hemorrhage, or evidence of acute intracranial pathology.  CT angiography of the neck noted cervical vasculature was patent without evidence of atherosclerosis, stenosis, or dissection.  CT angiography of the brain showed no vessel occlusion or stenosis identified about the circle of Willis.  There was a left superior hypophyseal artery aneurysm measuring approximately 2.2 millimeters (mm) across its neck and 2.2 mm from neck to dome.  The report stated the patient was admitted to telemetry for suspected seizure-like activity in the ED, likely in the setting of worsening anxiety and insomnia.  The plan stated the patient had severe anxiety and panic attacks that were untreated.  Urine toxicology was positive for tetrahydrocannabinol (THC).  

According to the Milliman Care Guidelines regarding seizures, the evidence did not support that the patient satisfied the criteria for inpatient care.  While the patient presented to the ED with tachycardia, her symptoms did not persist following treatment.  

Based on the above, the insurer's denial must be upheld.  The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.