Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented for an evaluation secondary to a fall. The patient reported that he had been found unconscious on his driveway by a neighbor. The patient reported that he had an additional fall in his driveway the following day. The patient had been walking up and down the driveway to improve his strength. The patient had a history of glioblastoma with resection, hypertension, osteoarthritis, obstructive sleep apnea on continuous positive airway pressure (CPAP), and benign prostatic hypertrophy. According to emergency room records, he was recently discharged home from previous admission from a near syncopal episode and a fall which resulted in multiple facial fractures on the right side. At that time, it was felt to be related to a seizure given his glioblastoma resection. The patient's wife reported that an hour and a half after returning home, the patient had run into a chair. He lost his balance, tried to reach a counter and missed and fell forward. There were no new injuries from this fall. The wife was concerned that she was unable to take care of the patient at home as he was not safe by himself.  

Laboratory testing revealed white blood cell count of 12.3, hemoglobin of 11.6, hematocrit of 34.1, and platelet count of 122. His initial troponin was 0.04. His pulse readings noted 70, 49, 44, and 57. The patient was assessed for fall, balance problems, seizure, and deep venous thrombosis prophylaxis. There was a plan for serial troponins and repeat electrocardiogram in the morning, social work evaluation for possible placement, repeat laboratory testing, and to continue with home medications. Physical therapy was to evaluate for stability and balance. The provider noted that the patient was able to get up and walk without difficulty. There was a plan to consult with neurology to determine whether or not the patient had a seizure during the initial fall. The provider noted that the patient would be too strong for short-term rehabilitation as 99% of the time he could get up and walk fine. The patient reported fluctuating confusion.  

Later during the admission, it was noted that the patient had nocturnal bradycardia. This was most likely related to underlying sleep apnea. He had not been wearing his CPAP due to facial fractures. The patient remained in sinus rhythm but was either bradycardic throughout the night or had sinus tachycardia when doing orthostatics. The wife reported that the patient's confusion was present prior to his surgery but the patient reported that it had worsened. An evaluation by Occupational Therapy revealed moderate cognitive impairment that was most likely caused postsurgical. It was unclear if steroids were contributing, so these were to be weaned.  

Computed tomography of the head was performed which showed right facial fractures with overlying soft tissue swelling, postsurgical changes in the left temporal region, but overall appearance was similar to prior. There was no definitive epileptiform discharges present. There was no hemodynamically significant stenosis. Neurology recommended continuing the current dose of Keppra twice a day since he was at increased risk for seizures. The patient was ultimately diagnosed with orthostatic hypotension. The patient reported that he felt more confused when standing. Flomax and Olmesartan were held with good effect. The provider stated that the patient's orthostasis was worsening his confusion due to hypoperfusion. At the time of discharge, the patient no longer had orthostatic hypotension. He was ambulating independently. He denied any chest pain or shortness of breath.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.