Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a history of laparoscopic cholecystectomy and a benign brain tumor presented with a one-month history of headache and blurry vision. The headache worsened over the past week and was described as occipital with radiation to the sides of the head, heavy in nature, and had an intensity of 8 out of 10. The pain worsened with head movement. The patient also reported right ear tinnitus but denied other associated symptoms. She experienced blurry vision in both eyes, with the left eye being worse in the morning but resolving by the afternoon. These symptoms were new to the patient. The review of systems was negative for nausea, vomiting, dizziness, photophobia, phonophobia, weakness, sensory changes, cough, shortness of breath, pain elsewhere, abdominal pain, diarrhea, or urinary symptoms.
In the emergency department, the patient's vital signs were stable with a blood pressure of 137/93 millimeters of mercury (mmHg), heart rate of 87 beats per minute, respiratory rate of 18 breaths per minute, temperature of 98.2, and oxygen saturation of 99 percent (%) on room air. Upon examination, the patient was lying comfortably in bed and showed no acute distress. Her central nervous system was intact, with the patient awake, alert, and oriented to person, place, and time. There were no motor or sensory deficits noted. There was no pallor or scleral icterus that was observed in the eyes. The mucous membranes were moist, and the neck was supple. Cardiovascular examination revealed normal first and second heart sounds, a regular rhythm, and no murmurs. The respiratory examination showed clear bilateral lung fields without crackles, rhonchi, or wheezing. The patient's abdomen was soft, non-tender, and non-distended, with positive bowel sounds. There was no edema in the extremities, and her peripheral pulses were palpable.

The laboratory evaluation showed a white blood cell count of 9.74, hemoglobin level of 13.3, hematocrit of 41.5, and platelet count of 304. Her sodium was 140, potassium 3.7, chloride 100, and bicarbonate was 28. Renal function tests revealed a blood urea nitrogen level of 11 and a creatinine level of 0.7. The glucose level was 106. The liver function tests showed slightly elevated levels of aspartate aminotransferase at 50 and alanine aminotransferase at 71, as well as alkaline phosphatase at 140. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The review of the medical records clearly demonstrated that the patient had no severe or persistent altered mental status, severe or persistent vomiting, or severe or persistent dehydration. The imaging studies did not demonstrate that the headache was associated with unruptured but symptomatic aneurysms of vascular malformations, venous sinus thrombosis, increased intracranial pressure, or cerebral spinal fluid leak. The review of the medical records did not reveal any suspicions the patient had a medication overdose-induced headache or 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 (Computed tomography) 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. Taking into consideration all these facts, there is no 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. Admission at an alternate level of care would have been reasonable.