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. He has history of CIDP (Chronic Inflammatory Demyelinating Polyneuropathy) on IVIG (intravenous immunoglobulin) therapy every three weeks and chronic steroids, as well as right peroneal DVT (deep venous thrombosis) on anticoagulant therapy. The patient also has history of one episode of seizure, treated with Keppra. EEG (electroencephalogram) findings were negative at that time. History of brain mass, last seen on imaging was also noted. The patient wears leg braces, but he was able to ambulate with a walker. His neurological baseline was notable for hand tremors, weakness, and diminished sensation on half calf downwards.

The patient presented to the emergency department with complaints of a right-sided headache and eye pain, with a pain level of 8/10, nausea, and vomiting as well as sensitivity to light and sound. He had similar headaches in the past but none recently. He denied weakness, numbness, and shortness of breath. His exam was essentially unremarkable, other than some bilateral hand tremors.  MRI (magnetic resonance imaging) and neurological consult were ordered.

While in the emergency department, the patient received Tylenol, Reglan, and IV (intravenous) fluids. Brain MRI (magnetic resonance imaging) showed an unchanged right superior parietal lobule enhancing nodule which was unchanged. No acute ischemic or hemorrhagic lesion was seen.

The patient was admitted for observation and management of his headache. Dilated eye exam by ophthalmology was normal, and no papilledema was seen.  Throughout his admission, the patient's headache improved. On the day of discharge he did not require any pain medication. The patient was deemed stable for discharge and was advised to have close outpatient follow-up.  The patient's claim for this hospital admission was denied as not being medically necessary.

No, the Inpatient admission was not medically necessary.
Medical necessity means a service, medication, or treatment is in accordance with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, duration, and considered effective for the illness or symptoms, and they must not be provided primarily for the convenience of the patient or physician. The treatment or procedure must not be more intensive than the same or similar service provided by a different provider or an alternative service that is at least as likely to produce an equivalent therapeutic or diagnostic result.

In the patient's case, ER (emergency room) note states that the patient had a headache with vomiting and photophobia similar to his prior headaches. Neurological examination was unchanged from his baseline. Brain imaging results were stable. The patient's headache has largely subsided in ER (emergency room), and there was no need in any ongoing intravenous interventions. The mental status was at the baseline. Therefore, acute inpatient admission was not clinically appropriate since the patient was clinically stable and could have been managed at a lower level of care. The treatment - acute inpatient care - was more intensive than an alternative service that is at least as likely to produce an equivalent therapeutic or diagnostic result (i.e., observation care). Therefore, the proposed treatment is not medically necessary.

The patient was at his baseline in terms of his exam and imaging, and the headache episode in question was similar to his prior episodes. The patient was clinically stable and could have been managed at a lower level of care.