Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with shunted hydrocephalus.  He is status post multiple shunt revisions and a Chiari decompression.

The patient presented to the Emergency Room with several days of headache.  He also complained of blurry vision and gait disturbance.  His heart rate was 61.  A head CT (computed tomography) showed stable placement of right ventricular catheter with interval enlargement of his left lateral ventricle and third ventricle.  His Certas valve was adjusted from 3 to a 2.  He was placed in observation status.

The patient's heart rate was 45.  A head CT (computed tomography) showed stable to minimally increased size of the atrium of the right lateral ventricle compared to the prior CT (computed tomography).  There was unchanged effacement of the cerebral sulci.

The patient was converted to a full inpatient admission.  His headache was improved (2-3).   He had nausea but no vomiting.  His heart rate was 61.

The patient's heart rate was 64.  A shunt tap was performed.  Only a small amount of CSF (cerebrospinal fluid) was able to be drawn back, and there was concern for possible shunt malfunction.

The patient underwent a shunt revision.  The proximal cattier and valve were found to be obstructed.  He was placed in the PICU (pediatric intensive care unit) postoperatively.  Overnight he had emesis twice and did require IV (intravenous) Zofran.  He was transferred to the pediatric floor.  His Certas valve was set at a 4.

The patient's IV (intravenous) Tylenol was changed from IV (intravenous) to oral as needed.  MRI (magnetic resonance imaging) of the brain showed interval decrease in size of the left lateral ventricles compared to head CT (computed tomography) performed previously. 

No, the Inpatient admission was not medically necessary.

The hospital stay was not medically necessary.  These days represent a delay in care.  The patient was admitted for observation and had a valve adjustment.  Repeat imaging the following day showed worsening of the hydrocephalus and continued symptoms, as well as bradycardia, concerning for increased intracranial hypertension.  A shunt tap, which was not performed until the next day, could have been performed during observation.  This would have shown poor function of the shunt, and the patient could have gone to the operating room after this shunt tap.  He would have then been discharged the following day..  A postoperative imaging (MRI [magnetic resonance image] or CT [computed tomography]) showing smaller ventricular size could also have been performed prior to discharge.

An observation status for a patient is reasonable when there is a question of a shunt malfunction.  Attempts to change the valve setting can be done.  However, once this does not work and the patient remains symptomatic and imaging shows worsening, then an intervention should occur.


Therefore, inpatient hospitalization was not medically necessary.  No further imaging was done to investigate shunt function, and, as stated above, the shunt tap could have been performed several days sooner.