Appeal type: Medical necessity
Decision: Upheld

Central Nervous System /Neuromuscular Disorder
Inpatient Hospital

The patient is a female with a past medical history significant for pseudotumor cerebri and obesity who was referred to the emergency department by her physician due to severe headache. The patient stated that she has had intermittent headaches, mainly in the frontal area of the head, for the last two years. Reportedly, within one week that preceded the day of admission, the headache became worse. The patient rated the pain as 7/10 in severity without radiation. It was not associated with nausea or vomiting, but she had blurry vision.

The patient was admitted to the hospital with a diagnosis of pseudotumor cerebri, benign intracranial hypertension, obesity. The patient was ordered a therapeutic lumbar puncture. Clear colored spinal fluid was collected into four tubes with the opening pressure of 44 centimeter (cm) of water (H2O). In addition, the patient was recommended to take Acetazolamide and follow up with ophthalmologist and neurologist as an outpatient.

The health plan's determination is upheld

The review of the medical records revealed that the patient was in overall stable clinical condition, including an unremarkable neurologic exam and unremarkable imaging studies. Therefore, I do not see strong indications for acute inpatient level of care.
According to the Merck Manual Professional Version,
 "Idiopathic intracranial hypertension occasionally resolves without treatment.
Treatment of idiopathic intracranial hypertension is aimed at the following:
- Reducing pressure
- Preserving vision
- Relieving symptoms"
"Serial lumbar punctures are controversial but are sometimes used, particularly if, while waiting for definitive treatment, vision is threatened."
Even though the lumbar puncture was performed, this was in general an outpatient procedure not necessitating admission at the acute inpatient level of care.
The review of the medical records demonstrated that at the time of the presentation to the hospital the patient was afebrile, hemodynamically stable, and had essentially normal physical exam including the neurologic exam. The results of the imaging studies did not demonstrate any clinically significant abnormalities that would necessitate admission at the acute inpatient level of care.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
MCG Health Inpatient and Surgical Care 23rd Edition Criteria for headaches was carefully reviewed with the medical records. Based on the guidelines, admission at the inpatient level of care is recommended for patients with headaches who presented with increased intracranial pressure. Even though technically this patient had a headache and increased intracranial pressure, these symptoms were typical for her chronic condition pseudotumor cerebri. This diagnosis had already been established. The review of the medical records did not demonstrate that the patient had any deterioration of vision that would prompt additional intervention.
This patient had a normal CT scan of the head and normal MRI of the brain, ruling out other serious clinical conditions that could manifest in headaches and increased intracranial pressure. Taking into consideration these facts, I do not think that this particular criterion was relevant in this case when the diagnosis had been already established.