Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a medical history of postpartum cardiomyopathy, hypertension, diabetes mellitus, and high cholesterol who presented to the emergency department due to worsening headache and dizziness. The patient described waking up in the morning with a severe headache localized in the left orbital area, which radiated across the front of her head. She also experienced neck pain and shoulder soreness. She denied having fever, chills, nausea, vomiting, or photophobia. She reported regularly taking two tablets of Aleve for her usual headaches, but this time, the headache did not improve even after taking lisinopril for her high blood pressure, prompting her emergency department (ED) visit. It should be noted that she had recently been admitted to another facility for hypertension, which worsened when she ran out of medications.
Upon arrival at the ED, her vital signs showed hypertension. In terms of her constitutional symptoms, she had no weakness, fever, or chills. Her eyes and ears, nose, and throat were normal with no visual changes, vertigo, or throat pain. The patient did not exhibit any neck pain or stiffness. She did not report cough, wheezing, hemoptysis, or shortness of breath in the respiratory system. There was no chest pain or palpitations in the cardiovascular system. For the gastrointestinal system, she denied abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, or hematochezia. She also did not have dysuria, frequency, or hematuria in the genitourinary system. Neurologically, she had no numbness or weakness. She did not experience joint pain or muscle ache in the musculoskeletal system, and there was no itching, burning, rashes, or lesions on her skin.
During the physical examination, the patient was afebrile, with a heart rate of 76 beats per minute (bpm), blood pressure of 135/96 millimeters of mercury (mmHg), and an oxygen saturation of 100 percent (%). She appeared well-developed and without any abnormalities in the general examination. The head, eyes, ears, neck, throat (HEENT) examination revealed no signs of trauma, and her eyes were normal, including extraocular movements. Her pupils were equal, round, and reactive to light and accommodation. Her conjunctiva and sclera were clear, and her oral mucosa was moist without any exudate. The neck was supple, and there was no jugular venous distension.

The review of medical records demonstrated that the services could have been provided at an alternate level of care since neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. The review of the medical records clearly demonstrated that the patient had no severe or persistent altered mental status, severe or persistent vomiting, or severe or persistent dehydration. The imaging studies did not demonstrate that the headache was associated with unruptured but symptomatic aneurysms of vascular malformations, venous sinus thrombosis, increased intracranial pressure, or cerebral spinal fluid leak. 
The review of the medical records did not reveal any suspicions the patient had a medication overdose-induced headache or vasculitis. There was no mention that the patient had the presence of papilledema, cerebral edema, mass effect, cerebral bleeding, ischemia, hydrocephalus, or uncontrolled seizures. There was no mention that the patient had focal neurologic signs. The shortness of breath was transient and did not require invasive or noninvasive mechanical ventilation or any other intervention necessitating admission at the acute inpatient level of care. The patient initially had an elevated blood pressure but no evidence of a hypertensive emergency.