Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is an adult who presented to the emergency department (ED), with dizziness and the inability to ambulate. The patient struck her head at work one week previously and was initially seen in the emergency department. The patient woke up the previous day with vertigo and dizziness that was progressively worsening. The patient was unable to ambulate and was unsteady on her feet and had two episodes of non-bilious non bloody vomiting but had not vomited since coming to the emergency department. The patient had no history of stroke or recent blood thinners. The patient was out of the therapeutic window for tissue plasminogen activator (tPA). The patient's examination at the time of presentation was significant for ataxic gait with near fall, abnormal right-sided finger-to-nose testing and positive Romberg's sign. A stroke code was activated for possible posterior cerebrovascular accident (CVA). An initial head computerized tomography (CT) scan and CT angiography were negative. The patient's blood pressure at the time of admission was 139/78 millimeters of mercury (mmHg). The patient was admitted to an acute level of care. Laboratory revealed a slightly elevated level of calcium at 11.1, with otherwise normal complete blood cell count (CBC) and comprehensive metabolic panel. A non-contrast brain magnetic resonance imaging (MRI) showed white matter changes out of proportion for the patient's age. The patient was seen by Neurology Service, and the plan was to obtain a pre-and post-contrast magnetic resonance imagining (MRI) to assess for multiple sclerosis (MS). The patient was otherwise treated symptomatically, and her symptoms mostly resolved while in the emergency department (ED). 

Once acute stroke was ruled out, the patient could have been discharged with plans for outpatient follow-up, as her symptoms improved significantly while in the emergency department. A diagnosis of a peripheral vestibulopathy could be made that does not require acute inpatient hospitalization. There was no evidence of any shortness of breath or any respiratory dysfunction, requiring pulmonary monitoring. 

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary" (American Health Information Management Association, 2018). 

Per Lee K. (2010), "To improve the speed of clinical assessment, diagnosis, and early management decisions for patients with TIA or stroke, a dedicated stroke team and protocol can be useful. Initial clinical assessment should be performed by physicians in the ED. The ABCD2 score, which considers age, blood pressure, clinical features, duration of symptoms, and diabetes history, predicts short-term stroke recurrence and can be key for helping ED physicians rapidly assess patients with suspected TIA or stroke." 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.