Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular-Parkinson's Disease. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's denial. 

The patient has a history of Parkinson's disease, orthostatic hypotension from autonomic dysfunction, hypertension, and dyslipidemia. She presented to the emergency room (ER) with dizziness, lightheadedness, and increasing weakness. The patient reported that she had a systolic blood pressure ranging from the 70's to 170 at home. She also endorsed foul smelling urine and urinary urgency. In the ER she was hemodynamically stable and had a blood pressure (BP) of 128/62. She was afebrile. She also had some garbled speech and ataxia. A computed tomography scan of the head showed age related changes. Her labs showed a positive urinalysis (UA). Chest X-ray was unremarkable. She was started on intravenous (IV) fluids and ceftriaxone. Orthostatic vitals were checked, and neurology was consulted who suggested findings are consistent with her history of autonomic dysfunction. The patient declined to adjust her medications. Physical therapy/occupational therapy recommended short term rehabilitation. Antibiotics were changed to Augmentin after her urine cultures grew E. faecalis. The patient had an episode of dizziness while on the commode with a systolic blood pressure (SBP) in the 70's. She was shifted to the bed and her SBP was in the 90's. She was given IV fluids and had no recurrence of symptoms. She was sent to rehabilitation with a plan to follow up with her primary care physician and neurologist. 

The inpatient admission was not indicated or medical necessity. The patient has a known history of autonomic dysfunction and orthostatic hypotension related to her history of Parkinson's disease. Autonomic dysfunction and orthostatic hypotension can be challenging to treat. No single drug or treatment can effectively mimic the actions of the sympathetic nervous system in different situations and a multipronged approach, combining non-pharmacological and pharmacological measures, usually is needed such as sudden change in posture, prolonged recumbency, straining during defecation and micturition, severe exertion, large meals, alcohol etc. Furthermore, associated deficits (such as cerebellar features in multiple system atrophy) may limit mobility in some, despite effective treatment of orthostatic hypotension. Any of the aforementioned factors can trigger the orthostatic hypotension and dizziness, it is important to get a detailed history of work on reversing the cause. She did not have any recurrence of the symptoms until later in the hospital stay. It is important to note that this was not a new diagnosis and the patient with autonomic dysfunctions that result in symptomatic hypotension will experience these frequent attacks during their lifetime. An outpatient plan and close contact with the primary care physician or the neurology service is very important. Based on Milliman Care Guidelines the inpatient admission is indicated in patients with acute bacterial labyrinthitis, acute stroke, vertebral artery disease. Hemodynamic instability that is severe and persistent despite intervention (one-time SBP of 70 improved quickly and this happened in settings when her risk was higher i.e., on commode and straining), severe and persistent vomiting, arrhythmias etc. Her episode of hypotension and dizziness while on commode was most likely triggered by straining and was vasovagal syncope. It was potentiated by her history of autonomic dysfunction. This also did not require inpatient admission. She also had urinary track infection (UTI), but she was not febrile, had no other signs of systemic illness, had no difficulty to take by mouth (PO) antibiotics, no concern for resistant strain and was suitable for oral antibiotics and lower level of care management.