Appeal type: Medical necessity
Decision: Upheld

Dx: Central Nervous System/ Neuromuscular Disorder
Tx: Inpatient Hospital
Denied: Inpatient Stay
Denial: UPHELD in whole

This case involves a male with a history of hypertension, coronary artery disease, and hemorrhagic cerebrovascular accident (CVA)  who presented to the hospital with weakness and fatigue lasting for five days. Over the past 48 hours, he experienced episodes of dizziness, with the room spinning when changing position, primarily upon standing. The symptoms were worse when he moved his head. He suffered two bouts of vomiting. The symptoms are similar to an episode 1 month before this presentation and resolved with meclizine.

The health plan's determination is upheld in whole.

The patient was admitted to the hospital with dizziness and unsteady gait, likely due to benign paroxysmal postural vertigo (BPPV). The patient was started on meclizine, and neurology was consulted to evaluate. He was also given additional antihypertensives for elevated blood pressure. The patient was admitted to the observation unit for vertigo, and Epley maneuvers were recommended.
Also, neurosurgery was consulted for the meningioma, as well as ear, nose, and throat (ENT).
ENT evaluated the patient, who agreed that the likely cause of the symptoms was benign paroxysmal positional vertigo and recommended Epley maneuvers and meclizine as needed.
The patient was also assessed by neurology, who reviewed all of the imaging. The Dix-Hallpike maneuver was positive on the left, and Epley maneuvers were performed. The patient was given self-instruction on Epley maneuvers. No further neurologic workup was recommended.
Cardiology was also asked to evaluate the patient reviewed all of the imaging studies, laboratory studies, as well as outpatient cardiac studies. They noted that the patient had chronic wall motion abnormalities, borderline low ejection fraction. They felt the patient's symptoms were not related to a cardiac etiology. They did not think that the patient's thoracic ascending aneurysm is contributing. They recommended an outpatient follow-up.
Finally, the patient was evaluated by neurosurgery for the left frontal meningioma, and they noted note that there was no indication for surgical intervention.
As mentioned previously, the patient had negative cardiac troponins. Urine toxicology screen was negative, and the thyroid function tests appeared in the normal range. Orthostatic blood pressures were negative. The hypertensive episode improved, with the adjustment in the antihypertensive regimen.
The patient was assessed by physical therapy, who after assessment discussed a rehab center versus home physical therapy with the patient when medically cleared.
The patient was eventually discharged with an adjusted regimen for his blood pressure medications, meclizine for his BPPV, and transferred to a skilled nursing facility for rehab.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
This patient had benign paroxysmal positional vertigo, which is a very benign diagnosis, self-limited, and is typically managed at a lower level of care status. The patient was evaluated by neurology, cardiology, neurosurgery, and ENT in the observation unit, cleared by all for discharge. There was no reason for an inpatient stay.
The patient had no evidence of acute bacterial labyrinthitis. Stroke was ruled out. There was no evidence of vertebral dissection on the imaging in the emergency department. The patient did not have hemodynamic instability. He had documentation that supports no orthostatic hypotension, no tachycardia, no altered mental status, or myocardial ischemia. The patient had no documented cardiac arrhythmias. There was no vomiting. The patient was recorded as having the ability to ambulate with a cane in the hallways within a short time frame. Therefore, there was no indication for inpatient hospitalization.