Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
This case involves a teen female who presented to the emergency department complaining of dizziness, headache, and vomiting.  The record stated the patient had a history of asthma and post-concussive syndrome.  She claimed to have almost fallen that morning due to dizziness and called an ambulance.  She reported vomiting 4 times and stated the dizziness worsened with sitting up and was accompanied by nausea.  Her problem list at the time of the assessment included temporomandibular joint disorder, pharyngitis, acute non-intractable headache, unspecified headache type, encounter for screening for Coronavirus disease 2019 (COVID-19), and allergic reaction. Blood pressure was 106/65 with a pulse of 59, temperature 97.6 degrees Fahrenheit, respirations 18, and pulse oximetry 100% on room air.  A recent magnetic resonance imaging (MRI) of the brain was within normal limits and recent laboratory testing with complete blood count (CBC), Basic metabolic panel (BMP), and urine pregnancy test were all negative.  An upper respiratory infection from 2 weeks prior had since resolved.  She was described as in acute distress and appeared uncomfortable and in pain.  On assessment, she had 3/5 right and left upper extremity weakness.  She was given a migraine cocktail x2, with Tylenol and Zofran.  She continued to have lightheadedness and nausea and was unable to tolerate anything orally.  Neurology was consulted as the patient was likely having a migraine. She was subsequently admitted for further work-up and care with the principal diagnosis of migraine.  She remained on inpatient status until she was discharged when her pain was better controlled.  

The Milliman Care Guidelines state that the goal length of stay for inpatient care for pediatric patients with headaches is 1 day.  Admission criteria must include 1 more the following to include 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, cerebral spinal 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, new onset focal neurologic deficit, need for intravenous fluids when the patient is unable to maintain oral hydration, and increased intracranial pressure or cerebral edema monitoring requirements. 
 
The information provided for the review noted that the patient was unable to tolerate anything by mouth given the consistent dizziness, nausea, and vomiting.  She was becoming more dehydrated given the vomiting and inability to keep down fluids.  She endorsed having a "bad headache" that required intravenous fluids to maintain hydration.  She continued to have significant migraine headache symptoms throughout the course of her stay until discharge, when she achieved adequate hydration, and her pain was more manageable.  Based upon the provided information, the inpatient stay was reasonable and allowed for appropriate management of the patient's symptoms.  The patient met the criteria for inpatient stay based upon the Milliman Care Guidelines.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is substantiated.