Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, Hypertension
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for hypertension, diabetes mellitus, gastroesophageal reflux disease (GERD), and hypothyroidism who arrived at the emergency department with complaints of elevated blood pressure and dizziness. The patient reported multiple episodes of sensation that the room was spinning around. The first episode occurred when the patient was looking down. The second episode occurred when the patient went to lie down. The patient denied neck pain, fever, recent travel, or sick contacts. The patient stated that they had difficulties walking for one week and had been feeling off balance but denied any focal weakness.
The review of systems was positive for nasal congestion, dizziness, speech changes, and headache. The rest of the review of systems was negative.  The patient was in no acute distress. The patient was obese and mucous membranes were dry. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The patient's lungs were clear to auscultation and without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam, including the neurologic exam, was normal.
A computed tomography (CT) scan of the head revealed a 7-millimeter (mm) ovoid-shaped, hypodensity in the left basal ganglia and further evaluation with magnetic resonance angiography (MRA) was recommended. There was no evidence of acute intraparenchymal hemorrhage of mass effect, midline shift or extra-axial fluid collection. An electrocardiogram (EKG) revealed normal sinus rhythm, normal PR-interval, normal QRS-complex, and slightly prolonged QT-interval. A chest x-ray showed no evidence of an acute cardiopulmonary process.
The patient was admitted to the hospital with hypertension, dizziness, hypokalemia, prolonged QTC-interval, diabetes mellitus, hypertension, and questionable hypothyroidism. In the hospital, the patient was seen by a neurologist who evaluated the patient and reviewed the computed tomography (CT) scan of the head. The neurologist recommended that the patient receive a magnetic resonance imaging (MRI) of the brain, initiation of treatment with meclizine, additional laboratory evaluation, echocardiogram, and carotid duplex. Furthermore, the neurologist recommended that the patient see an ear, nose, and throat (ENT) physician as an outpatient. The magnetic resonance imaging (MRI) of the brain was performed and interpreted as an unremarkable study. The 7-millimeter (mm) ovoid hypodensity seen in the left basal ganglia on the computed tomography (CT) scan of the brain represented a prominent Virchow-Robin (VR) space. There was no acute intracranial hemorrhage, mass effect, or hydrocephalus. An echocardiogram was also performed and demonstrated no significant abnormalities. The ejection fraction was normal. The carotid duplex study was also normal. The patient received potassium supplements for mild hypokalemia with complete normalization of the serum sodium levels. The blood pressure, which was elevated at the time of admission, came down with home medications that included Nifedipine and Labetalol. There was no evidence of hyperthyroidism since thyroid stimulating hormone (TSH) and free thyroxine (T4) were normal.
In the hospital, an endocrinologist also saw the patient due to reports of hoarseness and suspicion for hypothyroidism. Considering the presence of hoarseness of voice and hirsutism, the endocrinologist recommended the patient to follow up with an outpatient endocrinologist. During the hospital stay, the patient remained in stable clinical condition and was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The patient presented to the hospital with complaints of dizziness, however, the thorough evaluation performed in the hospital did not show any serious condition that would explain these symptoms including hemodynamic instability, acute bacterial labyrinthitis, cerebrovascular accident (CVA), brain hemorrhage, or cardiac arrhythmias of immediate concern. There were no warning signs on the physical exam, in imaging studies, or in the diagnostic tests.
According to the utilization review, admission was deemed necessary since the patient came with dizziness and hemodynamic instability. However, hemodynamic instability requires patients to have abnormal or unstable blood pressure that results in improper circulation and organs of the body do not receive adequate blood flow. Characterizations of hemodynamic instability include chest pain, confusion, hypotension, abnormal heart rate, loss of consciousness, restlessness, shortness of breath, and cold hands, arms, legs, or feet.
In this clinical case, the patient presented with a blood pressure of 158/102. At these blood pressure levels, it was unlikely that the patient could have any signs of hemodynamic instability. Taking into consideration all these facts, a lower level of care would be more reasonable, given the clinical circumstances. There was no compelling clinical reason the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was within the scope of a lower level of care.