Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ruptured AVM (arteriovenous malformation). 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is overturned. 

This case involves an adult female who presented to the emergency department (ED). The patient reported that she was increasingly shaky. The shaking woke her up at night. She endorsed sweats and chest pain. She was presently in addiction recovery. Vital signs of the patient noted a blood pressure of 147/112, heart rate of 80, respiratory rate of 18, and a pulse oximetry reading of 97% on room air. She had a history of intravenous (IV) drug use and was in recovery on Suboxone. The patient reported that the tremors had been ongoing and had worsened over the past week. She had also stopped using trazodone. She reported increasingly frequent staring spells and spells of full body shaking that resolved spontaneously. In the ED, a neuro exam noted only minor tremor and no clear asterixis. A detailed neuro exam was otherwise noted as normal. A computed tomography (CT) of the head demonstrated a left basal ganglia intraparenchymal hemorrhage. A computed tomography angiography (CTA) was consistent with underlying arteriovenous malformation (AVM). There was a plan to admit the patient for neurosurgery. Laboratory testing showed no electrolyte abnormalities. The patient had mildly elevated ammonia. This could be attributed to the patient's hepatitis C and possible cirrhosis. She was diagnosed with ruptured AVM. A diagnostic cerebral angiogram demonstrated no evidence of aneurysm or AVM as the cause of the patient's left basal ganglia hemorrhage. There was possible underlying cavernoma/developmental venous anomaly. She was evaluated for seizures which were felt to be tremors secondary to anxiety. 

 A summary of the patient's stay was documented and Milliman Care Guideline (MCG) as well as literature were referenced. The patient endorsed tremors, chest pain, full body shaking, night sweats, and staring episodes. Her history included intravenous drug use that have been treated with Suboxone and hepatitis C. Upon initial examination, she had intention tremor. CT of the head revealed left basal ganglia idiopathic pulmonary hemosiderosis with underlying AVM. She was found to have ruptured AVM. She was admitted for rupture left basal ganglia in the setting of IV drug use and hepatitis C. There was enlargement of the left superior ophthalmic vein. A venous varix was favored given recent normal cerebral catheter angiograph. It was stated that admission to the hospital was warranted as intracranial hemorrhage could not be ruled out. This was further complicated by Suboxone treatment and comorbid conditions. 

It was stated that the inpatient level of care was not medically necessary. The patient had shaking spells after stopping one of their medications. The patient was not unstable. The patient went home within 2 days of admission. The patient did not have unstable vital signs, need for emergency brain surgery, a brain medical problem that was severe, new weakness that was worsening, or weakness that was causing the patient to have difficulty breathing or eating. 

The patient presented to the hospital with complaints of increased shaking and chest pain. She had a history of IV drug use and was in recovery on Suboxone. She reported that she had tremors that had been ongoing but that they had worsened over the past week. She was initially diagnosed with ruptured AVM. Imaging revealed left basal ganglia hemorrhage. As per MCG, this would support admission. Furthermore, Up to Date highlights the potential for deterioration and the need for ongoing monitoring. This supports acute inpatient management. 

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 hospital admission is substantiated.