Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache 

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves an adolescent female who presented to the emergency department complaining of a headache on the right side that traveled down her neck to the right arm.  She reported numbness and tingling lasting approximately 1-2 minutes.  She reported a 19-pound weight loss in the past week.  Information stated that at the time of the patient's presentation to the hospital, her headache pain level was 8-9 on a scale of 1 - 10.  Examination concerns were for possible mild distal right arm weakness with reports of numbness of the entire right arm with an unclear sensory distribution.  There were difficulties obtaining reflexes in the right arm and urinalysis showed many bacteria, small leukocytes, with a white blood cell count of 9.  In the emergency department, treatment included Tylenol for pain control with neurology consulted and magnetic resonance imaging (MRI) recommended.  Diagnostic testing revealed a few scattered punctate foci of T2 (transverse relaxation time) FLAIR (fluid attenuated inversion recovery) signal hyperintensity in the subcortical white matter of the frontal lobes, moderately enlarged adenoids, and small central disc protrusion at C (cervical) 6-C7.  She was admitted to neurology services for further work-up.  After treatment for the headache and assessment with imaging; occupational therapy was done, and the patient was recommended for outpatient treatment.  She was subsequently discharged in stable condition. 

The Milliman Care Guidelines (MCG) 26th Edition states that clinical indications for admission of a pediatric patient for inpatient care includes severe pain that persists despite observation care, altered mental status that is severe or persistent, vomiting that is severe or persistent, dehydration that is severe or persistent, unruptured but symptomatic aneurysm, dissection, or vascular malformation, venous sinus thrombosis, increased intracranial pressure, cerebrospinal fluid leak, medication overuse, headache that has failed all outpatient management options, vasculitis requiring intravenous corticosteroids, intravenous antithrombotic therapy, or inpatient monitoring, severe neurologic findings requiring inpatient care such as papilledema, cerebral edema, mass-effect on computed tomography (CT) scan, cerebral bleeding, ischemia, or vasospasms, pituitary apoplexy, hydrocephalus, and anisocoria, seizures, new onset focal neurologic deficit, intravenous fluid requirements when the patient is unable to maintain oral hydration, and for those patients with increased intracranial pressure or cerebral edema - monitoring.  

The information provided for the review did not support that the patient displayed any signs or symptoms of these conditions that justify the inpatient level of care.  Based on the presenting findings during Emergency Department assessment, the patient could have been safely treated with further work-up conducted on an observational basis or outpatient basis. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.