Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nuchal rigidity.

Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.

The denial is upheld. 

This is a female patient who presented to the hospital with neck pain the day after a myelogram for right back/hip pain. The patient's neck pain was localized to the posterior neck described as cramping, tight, stiff that radiated to both shoulders with one episode of emesis post-myelogram. The patient also reported lightheadedness and stated that her head felt heavy and that her neck felt like it would "snap off". The patient's pain was alleviated with lying down and ice. The patient's first exam was negative for neurological deficit. The plan was for a computed tomography (CT) scan of the head and a Neurosurgery consult. The patient's head CT showed chronic sphenoid sinusitis with complete opacification on the left. Anesthesia evaluated and determined to defer blood patch at this time; they recommended trialing Motrin at home and to return for blood patch if unresolved. Neurosurgery noted positive nuchal rigidity. The patient was admitted for monitoring and pain control, and was placed on bedrest. 

As per literature, if post-lumbar puncture (LP) headache persists after a day of such treatment, an epidural blood patch (injection of a few milliliters of the patient's clotted venous blood into the lumbar epidural space) is usually effective. A blood patch may also be effective for spontaneous or traumatic cerebrospinal fluid (CSF) leaks, which rarely require surgical closure. The blood patch is thought to increase the pressure in the epidural space, decreasing the rate of the CSF leakage, regardless of where the CSF leak is. If normal CSF production exceeds the rate of leakage, the symptoms resolve.1

Because postdural puncture headaches (PDPH) tends to improve even without specific treatment and the epidural blood patch (EBP) has a relatively high rate of success, many practitioners reasonably seek neurological consultation if symptoms have failed to resolve after an arbitrary duration (e.g., 7-10 days) or number of EBPs (usually two or three). Consultation is always indicated if serious non-PDPH is suspected or cannot reasonably be ruled out. As previously mentioned, lateralizing neurologic signs, fever/chills, seizures, or change in mental status are not consistent with a diagnosis of PDPH or benign headache. Consultation is also appropriate for any headaches with atypical features. Proceeding with treatment measures directed toward PDPH under uncertain circumstances may hinder a correct diagnosis, cause critical delays in proper treatment, and can prove harmful. The EBP, for example, has occasionally been reported to produce detrimental increases in intracranial pressure. Because PDPH can be anticipated to resolve spontaneously, headaches that worsen over time and no longer have a positional nature should be strongly suspected to be secondary to subdural hematoma (SDH) (especially if there are focal neurologic signs or decreases in mental status). Under these circumstances, a neurological consultation should be obtained and diagnostic radiologic studies performed.2

Based on the review of the medical record and literature, the inpatient stay was not medically necessary for this patient. The patient's care could have been provided as an outpatient. The patient was neurologically and hemodynamically stable. The patient did not require intravenous (IV) fluids, around the clock IV pain medications, or at least every four hour neurological checks. The patient was able to void, eat a regular diet and take oral medications. The patient's CT scan of the head was negative for acute findings. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the Inpatient Admission is not substantiated. The insurer's denial should be upheld.