Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out carotid dissection and acute intracranial hemorrhage/mass, left eye pain
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This patient is a female who presented to the emergency department with complaints of left eye pain for one month.  She had seen an ophthalmologist days earlier and was given lubricating drops and lopressor eye drops which were used without relief.  Reportedly, the pain worsened and was associated with a one day history of jaw pain.  She denied blurry vision or headaches.  Vital signs were normal with exception of a blood pressure of 159/78.  Intraocular pressures were normal.  She was admitted for further evaluation of her left eye pain.  Differential diagnosis included temporal arteritis, migraine, primary tension headache, and trigeminal neuralgia.  The treating provider also wanted to rule out carotid dissection and acute intracranial hemorrhage/mass.  Her ESR/CRP was normal.  The computed tomography (CT) angiography of the head and neck was negative.  The patient was treated with prednisone and pain medications.  She showed improvement and was discharged with instructions to follow up with ophthalmology and her primary care physician.

According to Szatmary et al (2016), "Ocular or eye pain is a frequent complaint encountered not only by eye care providers but neurologists.  Isolated eye pain is non-specific and non-localizing; therefore, it poses significant differential diagnostic problems.  A wide range of neurologic and ophthalmic disorders may cause pain in, around, or behind the eye.  These include ocular and orbital diseases and primary and secondary headaches.  In patients presenting with an isolated and chronic eye pain, neuroimaging is usually normal."  Per Lee et al, "Although the main causes for eye pain are easily diagnosed by simple examination techniques that are readily available to a neurologist, sometimes the etiology is not as obvious and may require a referral to an ophthalmologist."  Per Bowen et al, "For patients with normal (eye) findings, it is important to consider migraine, trigeminal neuralgia, other headache syndromes, and cervicogenic headache."  

In this case, a patient with a one month history of left eye pain and one day of jaw pain was admitted for further evaluation after having previously seen an ophthalmologist and failing to respond to drops.  Upon admission, there was no complaints of visual loss or headache.  The CT was unremarkable as was ESR/CRP.  Although blood pressure was mildly elevated to 159/78, vital signs were otherwise stable.  There was no evidence of hemodynamic or respiratory instability.  There was no evidence of altered mental status or infection that would require intravenous medications.  Final diagnoses included hypertension and numbness of the face caused by trigeminal neuralgia versus persistent idiopathic facial pain, the work up of which could be performed on an outpatient basis.

Based on the records provided, the health care plan acted reasonably and with sound medical judgment and in the best interested of this patient.   Inpatient level of admission is not supported as medically necessary based on the records provided for review.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.