Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with a severe headache, nausea, and vomiting.
On presentation, she was afebrile with a blood pressure of 120/61, heart rate 76, respiratory rate 22, and an oxygen saturation of 100% on room air. The exam otherwise noted no obvious abnormalities. Labs resulted with a white blood cell count (WBC)of 7.1, hemoglobin (HGB) 10.9, platelets 138, sodium 137, potassium 4, blood urea nitrogen (BUN) 11, creatinine 0.73, liver function tests within normal limits, and serum pregnancy negative. A computed tomography (CT)scan of the head was negative. She was brought into the hospital with concerns for an intractable headache and plans for intravenous (IV) Zofran and morphine as needed and a neurology consultation.
She was seen by neurology with the assessment that she had developed a headache after recently having undergone a CT scan of her abdomen and pelvis in the setting of rectal fissure and had no meningismus or other neurologic deficits. The plan was for ongoing symptomatic treatment and to pursue magnetic resonance imaging (MRI) if her symptoms did not improve.
She remained hemodynamically stable. Her headaches were improved and she continued to apply nitroglycerin cream to her anal fissure and to be on laxatives. Lab results were unremarkable. The concern was for the ongoing headache and pain from her rectal fissure with plans for a surgery consult, IV fluids, Tylenol, and IV Toradol as needed.
She continued to have a headache. She was also noted to have urinary retention of 700 cubic centimeters (cc). Repeat labs were unremarkable. The plan was for ongoing IV fluids, symptomatic pain and nausea control, a urology consult, and MRI and magnetic resonance angiography (MRA) of the brain as well as discharge planning. The MRI and MRA of the brain showed no obvious abnormality. The urology assessment was that the patient had candida vaginitis with a recommendation to give Diflucan oral, azithromycin IV x1, ceftriaxone intramuscular, and to rule out human immunodeficiency virus (HIV) and other sexually transmitted diseases. The plan for her headache remained supportive measures.
The headache was noted to be somewhat better. Repeat labs were unremarkable. There was noted concern for candidal vaginitis. Surgery saw the patient with recommendations to continue hydrocortisone cream. The plan was to continue supportive measures in addition to IV cefoxitin and Diflucan. The patient was noted to complain of saddle anesthesia prior to admission.
She was noted to have urinary retention and an MRI of the lumbar spine was ordered given that the patient reported saddle anesthesia and lower extremity numbness and she continued to require straight catheterization for urinary retention.
A Foley catheter was placed. The MRI of the lumbar spine was performed which showed multilevel central canal and neuroforaminal stenosis without evidence of cord compression or cauda equina. She was ultimately discharged.
The issue under review is whether care at the inpatient level was medically necessary.
The requested health service/treatment of inpatient stay was not medically necessary. This is a patient who presented with a headache that was not associated with a fever, nausea, vomiting, or other neurologic deficits. She remained hemodynamically stable with pain controlled and not requiring frequent IV medications within a reasonable period of observation and imaging was negative. The patient otherwise was noted to have a rectal fissure for which treatment was hemorrhoidal cream in addition to noted urinary incontinence with mention that she may have had saddle anesthesia for which an MRI of the spine was pursued and showed no evidence of cauda equina. Though urinary retention resulted in this patient staying in the hospital beyond a reasonable period, it is noted that it took greater than (>) 24 hours to obtain an MRI with suspicion for cauda equina low and that urinary retention by itself is not generally a diagnosis that requires hospital-level care. Given this, this young patient with a history of anal fissure presenting with headache, nausea and vomiting subsequently noted to have urinary retention without cauda equina appears safe to have been treated at a lower level of care. Inpatient level of care was not medically necessary. The patient did not have hemodynamic instability, meningeal signs, headache that was intractable to observation therapies requiring IV medications every couple of hours, vasculitis, neurologic abnormalities associated with headache, or imaging suggestive of cauda equina causing urinary retention.