Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache, weakness
Treatment: Inpatient admission

The inpatient admission was medically necessary.

This is a female teen with medical history significant for asthma, food allergies, and eczema. She was referred to the ED with two-week history of weakness, headache, and dizziness, and two-day history of worsening throbbing constant headache associated with neck pain, lightheadedness, and photophobia. On the day of presentation, she was taken to the primary care doctor, where she was febrile to 102.3. 

In the ED, the patient's vital signs included temperature 102.3, heart rate 138, and blood pressure 120/70. Examination was significant for clear lungs, no acute distress, supple neck, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for leukocytosis (WBC [white blood count] 28.5K with 82% neutrophils), hyponatremia (sodium 132), and metabolic acidosis (CO2 [carbon dioxide] 18). A lumbar puncture was performed, with 6 WBCs, glucose 73, protein 15, and negative gram stain. Respiratory viral panel was positive for rhinovirus/enterovirus. A CT of the head was obtained revealing extensive bilateral sinus opacification that may represent acute sinusitis. 

The patient was treated with two normal saline boluses, a dose of ceftriaxone, a dose of acyclovir (to treated possibility of meningitis or encephalitis), and a migraine cocktail (Benadryl, Tylenol, Reglan) with some improvement in her headache. She was admitted to the pediatric floor for further care. Admission orders included continuation of ceftriaxone with transition to Augment when clinically improved, supportive care for fevers and pain, maintenance IV fluids, and regular diet for age. 

The patient remained afebrile during her hospital stay, but continued to complain of headaches despite treatment with Motrin and Tylenol. All cultures remained negative. Her antibiotics were transitioned to Augmentin to treat sinusitis. She received an additional normal saline bolus because of concerning orthostatic measurements. Brain MRI/MRV was obtained because of persistent headaches, revealing no intracranial abnormality and no evidence of dural venous sinus thrombosis, but opacification of the paranasal sinuses with an air-fluid level in the right frontal sinus that may indicate acute sinusitis. Her pain improved and by the afternoon, she was deemed stable for discharge. 

This female teen was referred to the ED for evaluation for possible meningitis because of acutely worsening headache with fever and neck pain/stiffness. She underwent comprehensive evaluation in the ED including lumbar puncture and CT scan with no obvious evidence of meningitis. However, imaging studies documented bilateral sinusitis. She was initially treated as for meningitis, receiving ceftriaxone, but with negative cultures, treatment was transitioned to Augmentin for the sinusitis. Despite appropriate antibiotic therapy, the headaches persisted. Imaging with MRI confirmed sinusitis with no evidence of other causes of headaches. With this information, she was discharged home, with close outpatient follow-up. The level of care that was given to this patient was most consistent with acute inpatient care. Lower level of care would not have been appropriate and would have been insufficient.