Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ears/Nose/Throat - Dizziness/Vertigo
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld. 

The patient is a male who presented to the hospital with dizziness and generalized weakness. The symptoms started after he ate some leftover chicken and rice. He described the dizziness as the room spinning around him, which had been constant. He had 1 episode of vomiting and watery diarrhea. After that, he became less interactive and somnolent. He was still able to ambulate without difficulty into the emergency department (ED). He denied vision changes, chest pain, or shortness of breath. Treatment in the ED included infusion of intravenous (IV) fluids, Zofran for nausea, meclizine for dizziness, and Ativan for nausea. His vital signs appeared stable, afebrile, with a blood pressure of 94/52 millimeters of mercury (mmHg). On exam, he had preserved strength in all four extremities with no leg edema. A urinalysis was negative for urinary tract infection (UTI). An initial lactate was 4.6, and on recheck after IV fluids, it was 2.6. COVID-19 testing, and influenza testing were negative. A computed tomography (CT) scan of the head showed no acute intracranial abnormality. A chest x-ray was negative for infiltrates but had some mild pulmonary edema.
The patient was admitted to the hospital with plans for brain magnetic resonance imaging (MRI), echocardiogram, thyroid function testing, and vitamin levels. The medical team consulted neurology, as he was still hypersomnolent, with the suspicion, due to benzodiazepines.
Critical care medicine consultation was obtained. They assessed the patient due to blood pressure in the 90s over 50s mmHg. They found the patient sleeping comfortably but arousable to commands. They recommended continuing IV fluids. A bedside ultrasound revealed intact cardiac function with no effusions. They signed off the case.
Neurology also assessed the patient and reviewed the images of the MRI.
The following day, the patient's vital signs improved, and he remained afebrile, with a resolution of the dizziness. The contrasted MRI showed no pathologic enhancement of the brain parenchyma. The neurologist recommended close follow-up with neurosurgery, with interval imaging, to rule out a low-grade developing glioma. Additional testing included lower extremity duplex due to mildly elevated D-dimer, which was negative. The patient had no further diarrhea episodes. The patient tested positive for cannabis. In discussion with the family, it was noted that he accidentally ingested three gummy bears at home, thinking they were regular gummy bears and did not contain marijuana. He ingested these shortly before the symptoms developed. The patient was released in stable condition to home.
At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is upheld in whole.
the requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient developed dizziness after ingesting marijuana-infused gummy bears at home, experiencing a hypersomnolent, dizzy, and confused state. On admission, he also received IV Ativan for nausea symptoms and was hypersomnolent and lethargic. He appeared dehydrated due to nausea, vomiting, and diarrhea, which was rapidly corrected with IV fluids. The blood pressure recovered nicely after the infusion of IV fluids and was stable. Brain MRI did not reveal stroke, an echocardiogram was unremarkable, and there was no evidence of deep vein thrombosis (DVT) or pulmonary embolism (PE). The patient's symptoms resolved within the initial timeframe, with complete recovery back to baseline. Therefore, there was no indication for admission to an inpatient level of care.