Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female child who presented to the Emergency Department (ED) with complaints of headache as well as neck pain and body aches. The patient also complained of nausea and emesis. She had tried warm compresses with Tylenol and Zofran in an attempt to decrease her headaches. She also complained of severe back pain. The documentation detailed that the patient's mother had taken her to the ED 3 times the prior week. The patient underwent a computed tomography (CT) scan which was negative as well as 3 COVID-19 tests, which were all negative. The patient's laboratory studies were within normal limits. The patient's past medical history included asthma. Her physical examination revealed a blood pressure of 125/77 with pulse of 84. Her oxygen saturation was 99%. The physician indicated that the patient was in acute distress and had musculoskeletal tenderness to the cervical spine. The patient complained of pain with sitting up, as well as abdominal tenderness. The recommendation was made for additional laboratory studies. The patient was noted to have trace ketones as well as trace amount of blood in her urine. The recommendation was made for a lumbar puncture. The lumbar puncture was unsuccessful in the ED.  Given the patient's persistent headache, the plan was to trial the patient on Compazine, Toradol and Benadryl, and to admit the patient to the hospital for further studies.  

The physician indicated that the patient had normal vital signs with evidence of photophobia as well as distress. The patient had increased back pain when bending over. The patient was neurologically intact. The patient's imaging and multiple diagnostic studies were normal. The patient was given a migraine cocktail and Valium which did improve her pain for approximately 6 hours; however, the patient's headache returned afterwards. The patient was admitted and was started on acetazolamide due to concern for idiopathic intracranial hypertension. The patient underwent additional imaging tests which all resulted normal. Interventional radiology was consulted, and a lumbar puncture was performed with noted improvement of the patient's symptoms. The patient did not have any further significant abnormalities while hospitalized and she was recommended for discharge. Given the lack of further acute adverse events, the patient was discharged with instruction to follow-up as outpatient.

The current literature indicates that a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. However, the submitted documentation does not indicate that the patient had a trial and failure of care at a lower level, such as observation. The patient's diagnostic workup was unremarkable with no acute adverse events or complications during her inpatient stay. 

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient. Literature supports that inpatient care rather than observation is required only if the patient's medical condition, safety or health would be significantly and directly threatened if care was not in an intensive setting. A patient must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be provided safely and effectively only on an inpatient basis.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.