Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Headache. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

The patient has a past medical history of a possible learning disability. The patient presented from the ophthalmology clinic for findings of papilledema. 
A review of systems was positive for generalized headaches and occasional blurred vision. The patient was afebrile (temperature of 98.7 Fahrenheit). The patient was described as alert and oriented. The patient's blood pressure was 108/67 millimeters of mercury (mmHg), with a pulse rate of 76 beats per minute (bpm), a respiratory rate of 18/minute, and an oxygen saturation of 100% on room air. A physical examination was unremarkable for positive clinical findings. The neurologic examination was reported as normal. 
Laboratory evaluation demonstrated a sodium of 140, a potassium of 4.6, a chloride of 104, a carbon dioxide (CO2) of 25, a blood urea nitrogen (BUN) of 6, a creatinine of 0.60, a white blood cell count (WBC) of 9.4, a hemoglobin of 12.0, a hematocrit of 37.0, and platelets of 298. An electrocardiogram (EKG) showed normal sinus rhythm with a left anterior fascicular block. A computed tomography (CT) of the head was negative for intracranial etiology. A chest x-ray revealed no evidence of pneumonia or effusion.
The patient was admitted for suspected benign intracranial hypertension or pseudo-tumor cerebri in the setting of chronic headaches. The documentation from ophthalmology cites 2 positive optic disc edema. The patient was treated with Diamox. The patient was evaluated with neurology and a plan for a magnetic resonance imaging (MRI) with possible lumbar puncture and drainage of cerebrospinal fluid (CSF) fluid was recommended. The patient subsequently left the hospital. 

At issue is the medical necessity for the inpatient stay. 

The health plan's determination of medical necessity is upheld, in whole. 

No, the requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at an alternate level of care for imaging studies. 
The patient was admitted for benign intracranial hypertension or pseudo-tumor cerebri in the setting of chronic headaches and occasional blurred vision. Inpatient level of care is not justified since the patient did not have vision loss or other acute neurologic deficits. Additionally, the patient already had an ophthalmologic evaluation conducted prior to admission. An alternate level of care would have been most appropriate for the CT scan and MRI.
The management of pseudo-tumor cerebri typically entails imaging studies and the treatment goals are to: 1) alleviate symptoms, and 2) to prevent vision loss. In this case, the patient did not warrant inpatient care for treatment (i.e., intravenous medications or repeated spinal fluid drainage) or evidence of worsening symptoms). Additionally, the patient did not have signs of acute vision loss. Weight loss and medical treatment may be utilized in cases without vision loss or in combination with surgical treatment. Cerebrospinal fluid shunting procedures and/or optic nerve sheath decompression is indicated for severe vision loss or headache unresponsive to medical management. Follow up visits and outpatient treatment are clinically reasonable for patients with pseudo-tumor cerebri who are asymptomatic or have mild symptoms.